SSA uses Form SSA-3373-BK to collect
information about a disability applicant's or recipient's
impairment-related limitations and ability to function. This
information, together with medical evidence, forms the evidentiary
basis upon which the initial disability process is founded. The
respondents are title II and title XVI applicants(or current
recipients undergoing redeterminations for) disability benefits.
This Non-Substantive Change Request adds a new fillable PDF version
of the form which SSA will use to replace the current PDF version,
allowing respondents to complete the form electronically prior to
printing and submitting it.
US Code:
42
USC 423 Name of Law: Social Security Act
US Code: 42
USC 1383 Name of Law: Social Security Act
US Code: 42
USC 405 Name of Law: Social Security Act
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:
(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;
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.