Report of Adult Functioning-Employer

Forms and Documents

Document Name	Status
Form SSA-3385-BK Report of Adult Functioning-Employer Form	New
Supporting Statement - SSA-3385.docx.doc Supporting Statement A	2016-07-19

IC Document Collections

IC ID	Document Title	Status
221156	Report of Adult Functioning-Employer Form	New

ICR Details

OMB Control No: 0960-0805	ICR Reference No: 201604-0960-014
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Report of Adult Functioning-Employer
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/25/2016
	Date Received in OIRA: 07/19/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2019	36 Months From Approved
Responses	3,900	0	0
Time Burden (Hours)	1,300	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Section 205 (a), 223 (d) (5) (A), 1631(d) (1), and 1631 (e) (1) of the Social Security Act (Act) require claimants’ applying for Social Security Disability Insurance or Supplemental Security Income benefits to provide SSA with medical and other evidence of their disability. 20 CFR 404.1512 and 20 CFR 416.912 of the Code of Federal Regulations provides detailed requirements of the types of evidence Social Security disability claimants and beneficiaries must provide showing how their impairment(s) affects their ability to work (e.g., evidence of age, education and training, work experience, daily activities, efforts to work, and any other evidence). Past employers familiar with the claimant’s ability to perform work activities completes Form SSA-385-BK, Report of Adult Functioning-Employer to provide SSA with information about the employees day-to-day functioning in the work setting. SSA and Disability Determination Services use the information Form SSA-3385-BK collects as the basis to determine eligibility or continued eligibility for disability benefits. The respondents are claimants’ past employers.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 1381 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 24927	04/27/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 43691	07/05/2016
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Report of Adult Functioning-Employer	SSA-3385-BK	Report of Adult Functioning-Employer

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ICR Summary of Burden

	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	3,900	0	0	3,900	0	0
Annual Time Burden (Hours)	1,300	0	0	1,300	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new form that increases the public reporting burden. See chart above for burden figures.

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Annual Cost to Federal Government: $8,644

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

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Common Form ICR:  No

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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: 07/19/2016

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