Function Report - Adult

ICR 201505-0960-011

OMB: 0960-0681

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2015-09-01
Supplementary Document
2015-07-23
IC Document Collections
IC ID
Document
Title
Status
9735 Modified
ICR Details
0960-0681 201505-0960-011
Historical Active 201311-0960-003
SSA
Function Report - Adult
Revision of a currently approved collection   No
Regular
Approved with change 09/01/2015
Retrieve Notice of Action (NOA) 07/23/2015
This collection is approved based on the revised materials provided by the Agency.
  Inventory as of this Action Requested Previously Approved
09/30/2018 36 Months From Approved 11/30/2015
2,085,721 0 4,221,656
2,120,483 0 4,292,017
0 0 0

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.

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
  
None

Not associated with rulemaking

  80 FR 24307 04/30/2015
80 FR 42600 07/17/2015
No

1
IC Title Form No. Form Name
Function Report - Adult SSA-3373, SSA-3373 Function Report -- Adult ,   Function Report - Adult

  Total Approved 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 2,085,721 4,221,656 0 0 -2,135,935 0
Annual Time Burden (Hours) 2,120,483 4,292,017 0 0 -2,171,534 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
When we last cleared this information collection in 2012, we reported a burden of 4,292,017 hours. Our current available data shows we overstated this number. Based on more accurate management information data, we are currently reporting a burden of 2,120,483 hours. This change stems from improved accuracy of management information used to track form usage and actual form submission, accounting for the significant decrease in responses.

$4,195,798
No
No
No
No
No
Uncollected
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

  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:
 
 
 
 
 
 
 
    (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.
07/23/2015


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