Pain Report - Child

SSA will insert the following revised Privacy Act and PRA Statements into the
form as soon as possible:
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Sections 1614(a)(3)(H)(i), 1631(d)(1), and 1631(e)(1) of the Social Security Act, as amended,
allow us to collect this information. We will use the information you provide to make a decision
on the named individual’s disability claim.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from making an accurate and timely decision on the named
individual’s claim.
We rarely use the information you supply for any purpose other than what we state above,
however, we may use the information for the administration of our programs, including sharing
information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census
and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notices, 60-0089, entitled Claims Folder System, and 600103, entitled Supplemental Security Income and Special Veterans Benefits. Additional
information about these and other system of records notices and our programs are available
from our Internet website at www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget
(OMB) control number. We estimate that it will take about 15 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.