Questionnaire for Children Claiming SSI Benefits

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
9392	Questionnaire for Children Claiming SSI Benefits	Modified

ICR Details

OMB Control No: 0960-0499	ICR Reference No: 201304-0960-005
Status: Historical Inactive	Previous ICR Reference No: 201102-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Questionnaire for Children Claiming SSI Benefits
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Preapproved	Conclusion Date: 08/23/2013
	Date Received in OIRA: 08/06/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2014	08/31/2014	08/31/2014
Responses	152,000	0	152,000
Time Burden (Hours)	76,000	0	76,000
Cost Burden (Dollars)	0	0	0

---

Abstract: Non-substantive change to the collection instrument Form SSA-3881-BK; revising words mental retardation to intellectual disability; no change in burden data. When 1) child claimants for Supplemental Security Income (SSI) benefits receive an unfavorable disability eligibility decision, and the people applying on their behalf want to appeal the decision; or 2) when children are currently receiving Disabled Child (DC) payments and the Social Security Administration (SSA) is reviewing their continued eligibility, these disability applicants and recipients need a mechanism to submit relevant evidence about the child's functioning. SSA uses Form SSA-3881, the Questionnaire for Children Claiming SSI Benefits, for that purpose. The respondents are parents or legal guardians of the child disability applicants/recipients.

---

Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Final or interim final rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 5233	01/28/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 18290	04/01/2011
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Questionnaire for Children Claiming SSI Benefits	SSA-3881 BK

---

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	152,000	152,000	0	0	0	0
Annual Time Burden (Hours)	76,000	76,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Due to budgetary constraints, SSA has been conducting fewer disability reviews; thus the decrease in the overall reporting burden.

---

Annual Cost to Federal Government: $1,558,480

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/06/2013

---