Supporting Statement for Form SSA-3371-BK
20 CFR 404.1512 and 416.912
OMB No. 0960-0540
A. Justification
Introduction/Authoring Laws and Regulations
Sections 1614 (a)(3)(H)(i) and 1631(e)(1) of the Social Security Act (Act) require claimants for Social Security Administration (SSA) disability payments to furnish medical and other evidence of disability as required to prove their disability. Disability regulations found in 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations require individuals to provide medical evidence and, if SSA asks for it, further evidence, when they apply for SSA payments. Further evidence may include: evidence of age, education, training, work experience, daily activities, efforts to work, and any other evidence showing how the impairment(s) affects the ability to work or, in the case of a child, how the claimant functions. Section 1631(d)(1) of the Act provides the Commissioner of Social Security with the full power and authority to make rules and regulations, establish procedures, and adopt reasonable and proper rules for the nature and extent of the evidence as well as the methods of taking and furnishing the same to evaluate the alleged disability.
Description of Collection
SSA requests information on Form SSA-3371-BK to provide disability interviewers, as well as applicants or claimants in self-help situations, with a convenient means to record information about the claimant’s pain or other symptoms. The State disability determination services (DDS) adjudicators and administrative law judges then use the information to assess the effects of symptoms on function for purposes of determining disability under the Social Security Act. The respondents are applicants for or claimants of Supplemental Security Income (SSI) payments.
Use of Information Technology to Collect the Information
SSA did not schedule Form SSA-3371-BK for electronic implementation under the agency’s Government Paperwork Elimination Act plan due to its low priority status and SSA’s limited resources. However, in the future we will examine this form as a possible candidate for electronic implementation.
Why We Cannot Use Duplicate Information
The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents
This collection does not significantly affect small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
SSA uses the information and medical evidence we collect on this form as the basis of the initial disability evaluation process. If we did not collect this data, we could not discharge our mandate to make payments to disabled claimants, as we would not have the means to determine if claimants are truly disabled. We cannot collect the information less frequently, as we require this data every time a claimant files for SSI payments. There are no technical or legal obstacles that prevent burden reduction.
Special Circumstances
There are no special circumstances that would cause this information collection to be conducted in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on November 9, 2012, at 77 FR 67435, and we received no public comments. SSA published the second Notice on January 8, 2013, at 78 FR 1296. If we receive comments in response to the 30-day Notice, we will forward them to OMB.
Payment or Gifts to Respondents
SSA provides no payment or gifts to the respondents.
Assurances of Confidentiality
The information provided is protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Approximately 250,000 respondents use the SSA-3371-BK annually. We estimate it takes 15 minutes to complete the form for a total burden of 62,500 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
Annual Cost to the Respondents (Other)
There is no known cost burden to the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $1,540,000. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).
B. Collections of Information Employing Statistical Methods
SSA does not use statistical methods for these information collections.
| File Type | application/msword |
| File Title | September 2000 |
| Author | John V Hailman |
| Last Modified By | 889123 |
| File Modified | 2013-01-08 |
| File Created | 2012-10-12 |