Addendum to the Supporting Statement for 0960-0144

Addendum to the Supporting Statement for Form SSA-3441-BK

Disability Report-Appeal

20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 422.140, 404.1713, 416.1513, 404.1740(b)(4), 416.1540(b)(4), and 20 CFR 405, Subpart C

OMB No. 0960-0144

General Revisions to the Collection Instrument

The Office of Disability Programs at Social Security formed a workgroup to revise the paper SSA-3441-BK, Disability Report Appeal. The workgroup included various headquarters’ components involved in disability case processing. Based on the workgroup’s suggestions, we are making the following general changes throughout the form:

• Change #1: We are making changes to improve the efficiency of the form to make it consistent with the look and feel of the revised SSA-3368 Adult Disability Report.

Justification #1: We are doing this to ensure efficiency, effectiveness, and continuity when we revise the agency’s disability programmatic forms.

• Change #2: We reviewed the current paper form and are making changes to the sections that collect information about the claimant’s conditions, medical treatment, activities, work and education/training.

Justification #2: We are doing this to ensure we use consistent terminology in all modalities of this information collection.

• Change #3: We are rearranging the order of the sections to create a better flow within this information collection.

Justification #3: We are doing this to logically group them for the claimant.

• Change #4: We are eliminating questions that collect information already collected on the SSA‑561 or SSA-501, or that add no value to case development.

Justification #4: We are doing this to avoid adding burden to the claimant by requesting information we do not need, and to ensure the claimant does not provide duplicative information to SSA.

• Change #5: We are removing the references to the “ability to work.”

Justification #5: We are removing these references because children and adults use this form for appeal, and ability to work is generally not necessary for child cases.

We believe these changes will result in a user friendly and efficient collection of information.

Below is a section-by-section description of the specific changes we are making to the paper form. The electronic versions collect the same information using EDCS screens and Webpages (i3441), and will reflect these revisions:

Detailed List of Revisions to the SSA-3441-BK

Instruction cover sheet

• Change #1: Reworded and modified the formatted of the instructional cover sheet

Justification #1: We are updating the instructional page for clarity.

The Privacy Act and Paperwork Reduction Act

• Change #2: We are making wording changes to both the Privacy Act and the Paperwork Reduction Act.

Justification #2: We are making these revisions based on the updated Statements provided by the Office of Privacy and Disclosure (Privacy Act) and Center for Reports Clearance (Paperwork Reduction Act).

“For SSA Use Only”

• Change #3: We are removing “Individual is filing:” text, and the claim level check boxes: Reconsideration, Request for Review by Federal Reviewing Official, Reconsideration for Disability Cessation, Request for ALJ Hearing.

Justification #3: This information is out-of-date and no longer needed by the SSA Field Office.

• Change #4: We are removing “Date of Last Disability Report” field.

Justification #4: This information propagates from SSA internal systems when we create the case electronically in EDCS. Therefore, we no longer need to request the information.

Instructions below “For SSA Use Only”

• Change #5: We are adding text to explain whose information the respondent should enter on the report.

Justification #5: This instruction text is necessary to clarify whose information should be provided on the form, since this form can be completed by someone other than the claimant.

Section 1 – Information About The Disabled Person

• Change #6: We are adding language to the phone number block to capture information needed for phone numbers outside of the United States. We are also adding instructions to provide the IDD and country codes, Province and Postal Code. We will make this change consistent throughout the form.

Justification #6: We are adding this information to accommodate users outside the United States since this form can be used by individuals filing for Social Security disability outside of the United States.

• Change #7: We are removing checkboxes for “Your Number,” “Message Number,” and “None.”

Justification #7: We no longer need the type of phone (home, work, cell, TTY), therefore, we are removing the information that is no longer relevant.

• Change #8: We are adding “Check this box if you do not have a phone or a number where we can leave a message.”

Justification #8: SSA examiners find this information useful during case adjudication. When a claimant checks the box, it indicates the examiner may need to contact the claimant at an alternate phone number or by mail. It also alerts the examiners that they may need to ask the field office for assistance in locating the claimant if they require communications regarding the case.

• Change #9: We are adding a space for an alternate phone number.

Justification #9: SSA examiners find alternate phone numbers useful when they are unsuccessful in attempts to contact the claimant at the daytime phone number provided.

• Change #10: We are adding space for an email address.

Justification #10: We are adding this new optional information block for consistency with our other disability report forms.

Section 2 –Contacts

• Change #11: Created SECTION 2 – CONTACTS.

Justification #11: We are creating this section to improve the flow of the form and ask all questions related to contacts in one section. This involves moving old question 1.D., which collects the name, relationship and address of someone other than the claimant’s doctor that knows about the claimant’s condition, to this section and moving the form complete information from old SECTION 10—Remarks. All contact information collected on the form will be located in this section. We are adding the Contacts section to improve the efficiency of the form and make it consistent with the look and feel of the revised SSA-3368 Adult Disability Report.

• Change #12: We are adding language to capture information needed for foreign addresses and phone numbers, and we are adding instructions to provide the IDD and country codes for the phone number and Province, Postal Code and Country, for the address.

Justification #12: The form is used by individuals that reside outside of the United States that file an appeal for Social Security disability. The language we are adding makes it clear where to include information specific to foreign address and phone numbers.

• Change #13: We are adding a question about the contact’s ability to speak and understand English, as well as a preferred language if English is not spoken.

Justification #13: The DDS needs this information when contacting the respondent either by phone or in writing. By adding this information, the DDS is aware of the need for an interpreter to communicate with the contact.

• Change #14: We are moving the information about who is completing the form from Section 10 – Remarks, to the new Section 2 – Contacts. In this new Sectio 2, we are labeling the information we collect for the form completer 2.F through 2.J. As we did in other sections, we are adding information necessary to collect foreign addresses and phone numbers.

Justification #14: We are grouping all contact information together to provide a better flow for the claimant. This will allow for easy reference to the contact in 2.A, who may also be the form completer, and eliminates the need for additional entries.

Section 3 – Medical Conditions (old Section 2 – Information About Your Illnesses, Injuries, or Conditions)

• Change #15: Renaming section title.

Justification #15: We are renaming this Section for brevity and clarity for the claimant. We need information about the claimant’s medical conditions. By labeling the section Medical Conditions, it is clearer than Illnesses, Injuries or Conditions.

• Change #16: Eliminating old question 2.B. which asked about new physical or mental limitations because of the illnesses, injuries or conditions.

Justification #16: We are making this change because the question did not fit logically into the “Medical Conditions” section. We collect similar information about the claimant’s limitations due to their medical condition in the “Activities” section. We do not need to collect information in more than one place.

• Change #17: We are rewording old questions 2.A. and 2.C.

• Justification #17: The new wording specifically asks the claimant if they have any new, or any changes to their current, physical or mental conditions. If the claimant answers “yes” to either question, we ask for a description. If the claimant answers “no,” they can move to the next question they do not need to provide details. We reworded these questions for clarity and brevity.

Section 4 – Medical Treatment (old section 3 – Information About Your Medical Records)

• Change #18: We are renumbering and renaming this section from “SECTION 3 - INFORMATION ABOUT YOUR MEDICAL RECORDS” to “SECTION 4 - MEDICAL TREATMENT.”

Justification #18: We are changing the title for clarity and brevity.

• Change #19: We are renumbering and rewording the old question 3.C. about other names used on medical records to ask as a yes or no question, and leave space for the claimant to provide other names used.

Justification #19: Question regarding other names used will become question 4.A. and will be reworded for clarity and brevity.

• Change #20: We are renumbering and combining old questions 3.A. and 3.B. which ask the claimant about medical treatment received since they last told us about their medical treatment.

Justification #20: We are combining these questions as they essentially ask for the same information: A asks about illnesses, injuries or conditions related to physical allegations and B asks asking about emotional or mental problems. Therefore, we are combining them. In addition, we are rewording for clarity and brevity.

• Change #21: We are adding question 4.C “What type(s) of conditions(s) were you treated for, or will you be seen for?” with checkboxes for “Physical” and “Mental (including emotional or learning problems).”

Justification #21: If the claimant selects yes for questions 4.B. this question provides an area for them to explain the type of condition they were treated for.

• Change #22: We are rewording and formatting the instructional text to better explain what types of medical treatment we would like the claimant to provide in 4.D.

Justification #22: We are rewording the instructional text for clarity.

• Change #23: We are combining the collection of information in the old 3.D. DOCTOR/HMO/THERAPIST/OTHER with the old 3.E. HOSPITAL/CLINIC.

Justification #23: Collecting information together is consistent with the current SSA-3368.

• Change #24: We are moving the old SECTION 5 – TESTS into this section.

Justification #24: The tests are now associated with the specific provider or facility listed. This change is consistent with the current SSA-3368.

• Change #25: We are placed the tests in alphabetical order.

Justification #25: Alphabetical order increases ease of use and clarity.

Section 5 – Other Medical Information

• Change #26: We are creating a new section, SECTION 5 – OTHER MEDICAL INFORMATION, and moving the old question 3.F. that collects information about non-medical sources that may have medical information about the claimant.

• Justification #26: The information provided in new Section 5 – OTHER MEDICAL INFORMATION is related to non-medical sources (i.e., Workers Comp, Voc Rehab, attorneys, Welfare Agencies, etc). Separating this from the medical sources will be easier for the claimant to understand.

Section 6 – Medicines (old section 4)

• Change #27: We are renumbering this section from “SECTION 4 – MEDICATIONS” to “SECTION 6 – MEDICATIONS.”

Justification #27: The new flow of the form requires us to renumber the section.

• Change #28: We are rewording question from, “Are you currently taking any medications for your illnesses, injuries or conditions?” to “Are you currently taking any medications (prescription or non-prescription)?”

Justification #28: Rewording the question for clarity. In addition, we are adding the words “prescription or non-prescription” to let the claimant know we need to know about all medications, not just those prescribed by a doctor.

Section 7 – Activities

• Change #29: We are changing the title of this section from “SECTION 7 – INFORAMTION ABOUT YOUR ACTIVITIES” to “SECTION 7 – ACTIVITIES.”

Justification #29: We are making this change for clarity and brevity.

• Change #30: We are combining old questions 7.A. and 7.B., related to personal needs and daily activities into a single question, and providing examples of daily activities.

Justification #30: It is often difficult for the claimant to distinguish the difference between their ability to care for their personal needs and their daily activities. By combining and rewording the question it should be easier for the claimant to understand what information about their daily activates we would like to collect in this section.

Section 8 – Work and Education (old section 6 – Updated Work Information and 8 – Education/Training Information)

• Change #31: We are combining old SECTION 6 – UPDATED WORK INFORMATION with SECTION 8 – EDUCATION/TRAINING INFORMATION.

Justification #31: We are combining these sections for clarity and brevity, and to improve the flow of the form

• Change #32: We are rewording the work activity question from old section 6 to ask, “Have you had earnings (before taxes and deductions) greater than $1010 in any month? ‘Yes’ or ‘No?’”

Justification #32: By rewording the question and specifically asking if the claimant made more than SGA (currently $1010 a month) it will help the Field Office (FO) streamline work activity development (SSA-821, Work Activity Repot - Employee). If the claimant answers “no,” no work activity development is necessary. If “yes,” the FO will develop for work activity.

Section 9 – Vocational Rehabilitation, Employment or Other Support Services Information

• Change #33: Renamed section title from “SECTION 9 – VOCATIONAL REHABILITATION, EMPLOYMENT, OTHER SUPPORT SERVICES INFORMATION, OR INDIVIDUALIZED EDUCATION PROGRAM” to “SECTION 9 - VOCATIONAL REHABILITATION, EMPLOYMENT OR OTHER SUPPORT SERVICES INFORMATION,” removing “Individualized Education Program” from the section title.

Justification #33: We are removing “Individualized Education Program” from the section title because it falls under Other Support Services which is already in the title of the section.

Section 10 – Remarks

• Change #34: We are rewording the instructional text which explains what to include in the remarks section of the form.

Justification #34: We are rewording for clarity and brevity.

• Change #35: We are moving the information about the person completing the form, if other than the claimant, to Section 2 – Contacts. (Name, eMail, Address, Telephone, Relationship to the Claimant).

Justification #35: As mentioned for Section 2 above, we are moving all information related to persons other than the claimant to one section (Section 2 – Contacts). This is consistent with other disability report forms.

New iAppeals Attachment Utility Function:

The new Attachment Utility function will be a part of the iAppeals application allowing users to attach and submit documents, such as medical records, supporting a claimant’s appeal (see included screenshots). We expect the Attachment Utility option will decrease the need for applicants to fax, mail, or hand-carry paper documents into SSA field offices (FO). The purpose of the Attachment Utility is to create an electronic document submission process.

The iAppeals Attachment Utility will enable:

• Internet users to quickly and easily upload files associated with their claim from their computer to the iAppeals application;

• Social Security Administration (SSA) staff users to:

• Identify iAppeals that have uploaded documents;

• Retrieve and view documents electronically;

• Delete files when they are deemed to be unnecessary;

• Delete, print, and send documents to the electronic folder for retention;

• Collect Management Information (MI) for usage, demographics, and failures from the internet application and the internal document processing tool.

The above iAppeals Attachment Utility improvements are consistent with our agency’s strategic goal to provide quality services, and improve the speed and quality of our disability process.

SSA currently receives approximately 90,000 iAppeals per month, and attorney and non‑attorney representatives complete about 65-75% of them. Since we recently implemented a policy requiring mandatory iAppeals usage for representatives seeking direct pay, we want to make it easy and convenient for them to attach supporting documents, and for the FO staff to open, review, and include the supporting documents in the appropriate electronic retention file. Within one year after release, our goal is for 50% of iAppeals filed by representatives to include attached documents.

We expect this new process will reduce time for FO mail processing, re-contacts, and the need for faxing documents into the electronic folder. We also believe additional savings could come from reductions in material costs associated with printing, faxing, and shredding of paper documents.

This release will allow claimants or their representatives to upload documents directly to the Social Security Administration (SSA), eliminating the need to submit the documents by mail or fax. This will save the users time and expense, while taking away a large workload for FO employees. Since the new Attachment Utility will streamline the current process, we do not anticipate any change in the current burden for iAppeals.

We are making the following changes to the iAppeals Screens (i501, i561, and i3441) to accommodate the new Attachment Utility function:

• Change #1: We are replacing the “Submit” button with “Next” button on the “Overall Summary” screen (previously the “Review and Submit Your Request for Hearing” screen).

Justification #1: The next button will take respondents to the “Attach Files” screen.

• Change #2: We are adding the “Attach Files” screen

Justification #2: This screen will allow respondents to add and submit files (evidence and other documents), along with an appeal request, through iAppeals. This option will eliminate the need to mail or hand carry documents into a field office.

• Change #3: We are adding information about attachments to the “Disability Appeal (Confirmation)” screen (previously the “Print Your Reentry Number and Receipt” screen).

Justification #3: We will let an applicant or third party know whether the appeal and attachments were successfully submitted.

SSA will implement all the above changes upon OMB’s approval of this information collection request, with the exception of the new Attachment Utility function which we intend to implement in 2015.