Supporting Statement - 0144

Supporting Statement for Form SSA-3441

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

A. Justification

1. Introduction/Authoring Laws and Regulations

Sections 205(a), 223(d), and 1631(e) of the Social Security Act (Act), as well as 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations (Code) require individuals filing for Social Security or Supplemental Security Income (SSI) benefits based on disability to provide evidence showing how their impairment(s) affect their ability to work or function. 20 CFR 404.916(c) and 416.1416(c) state that SSA will include any new evidence applicants submit in connection with their request for reconsideration in this review. Section 205(b) of the Act, as well as 20 CFR 405, Subpart C, and 20 CFR 422.140 of the Code, requires the Social Security Administration (SSA) to provide a reconsideration of an initial denial at the State Disability Determination Services (DDS) level, and an evidentiary hearing at the reconsideration appeal level, for individuals who appeal an unfavorable disability determination. SSA denies the claim when we find the physical or mental impairment for which such benefits are payable to have ceased; not to have existed; or not to be disabling. 20 CFR 404.1713 and 416.1513, which include mandatory use of electronic services, as well as 20 CFR 404.1740(b)(4) and 416.1540(b)(4) require a representative requesting direct fee payment to conduct business with us electronically at the times and in the manner we prescribe.

2. Description of Collection

SSA requires disability applicants who wish to appeal an unfavorable disability determination to complete Form SSA-3441. This form allows claimants to disclose any changes to their disability or resources that might influence SSA’s unfavorable determination. SSA may use the information to: (1) reconsider and review an initial disability determination; (2) review a continuing disability; and (3) evaluate a request for a hearing. The information SSA requests on the SSA‑3441 facilitates collecting medical and nonmedical information to support the applicant’s request for reconsideration; request for benefits cessation appeal; and request for a hearing before an administrative law judge (ALJ). The information we collect also assists the State DDSs and administrative law judges (ALJs) in: (1) preparing for the appeals and hearings; and (2) issuing a determination or decision on an individual’s entitlement (initial or continuing) to disability benefits. We collect the information via the SSA-3441-BK (paper form); Electronic Disability Collect System (EDCS); and i3441 Internet screens. The respondents complete the SSA-3441 by themselves either on paper or online. If the respondent completes the paper form, they mail it ahead of time or bring it into the field office (FO) when they have an appointment for an interview, and a claims representative keys the information into EDCS. If the respondent completes the i3441, the Field Office uses the information to file the claim. Respondents are individuals who appeal denial, reduction, or cessation of Social Security disability income and Supplemental Security Income (SSI) payments; who are requesting a hearing before an ALJ; or their representatives.

3. Use of Information Technology to Collect the Information

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created two electronic versions of form SSA-3441. SSA designed the electronic methods to collect the same information as the paper form, but they may be formatted differently and may include certain enhancements (e.g., instructions for claims representatives, help screens, dynamic pathing, etc.) to guide the interviewer or applicant through the appeal process. Based on our data, we estimate approximately 99.7% of the total responses are either collected through EDCS screens, or via the Internet version of the form (i3441).

4. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it preclude duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting It Less Frequently

If we did not use Form SSA-3441, the public would have no way to apply for reconsideration, benefits cessation appeal, or for a hearing before an ALJ. This would violate Sections 221(c) and (d) of the Act. Because we collect the information once, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on April 18, 2017, at

82 FR 18335, and we received no public comments. The 30-day FRN published on June 27, 2017 at 82 FR 29136. If we receive any comments in response to this Notice, we will forward them to OMB.

9. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

10. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

11. Justification for Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Annual Burden (hours)
SSA-3441-BK (Paper Form)	2,396	1	45	1,797
Electronic Disability Collect System (EDCS)	476,771	1	45	357,578
i3441 (Internet Form)	1,046,938	1	28	488,571
Totals	1,526,105			847,946

The total burden for this ICR is 847,946 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden to the respondents.

14. Annual Cost to Federal Government

The annual cost to the Federal Government is approximately $53,870. This estimate is a projection of the cost for printing and distributing the collection instrument.

15. Program Changes or Adjustments to the Information Collection Request

There are no changes to the public reporting burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

For the paper Form SSA-3441-BK, SSA will not publish the OMB approval expiration date. OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public‑use forms with life cycles exceeding the OMB approval date. Since SSA does not periodically (e.g., on an annual basis), revise and reprint its public-use forms, OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, thereby avoiding Government waste.

For the electronic versions of the form (EDCS-3441 and i3441), SSA is not requesting an exception to the requirement to display the OMB approval expiration date.

18. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

2. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.