Supporting Statement - 0720

Supporting Statement for

Certification of Low Birth Weight for SSI Eligibility (SSA-3830)

20 CFR 416.931, 416.926a(m) (7) & (8) and 416.924

OMB No. 0960-0720

1. Justification

1. Introduction/Authoring Laws and Regulations

Section 1633 of the Social Security Act (Act) allows the Commissioner of the Social Security Administration (SSA) to make appropriate or necessary administrative and other arrangements to carry out the functions of the agency under Title XVI of the Act. Section 1614 of the Act provides the rules under which SSA makes disability determinations for individuals under age 18. Section 20 CFR 416.931 of the Code of Federal Regulations allows SSA to pay benefits before making a formal finding of disability if we find the claimant is presumptively disabled. Section 20 CFR 416.926a(m)(7) and (8) provide that we consider certain low birth weight infants disabled at least until they attain age 1. Section 20 CFR 416.924 describes the rules for a formal determination of disability in a childhood case.

2. Description of Collection

Hospitals and claimants use Form SSA-3830 to provide medical information to local field offices (FOs) and Disability Determinations Services (DDSs) on behalf of infants with low birth weight. FOs use the form as a protective filing statement, and the medical information to make presumptive disability findings, which allow expedited payment to eligible claimants. DDSs use the medical information from SSA-3830 to determine disability and continuing disability. The respondents are hospitals and claimants who have information identifying low birth weight babies and their medical conditions.

3. Use of Information Technology to Collect the Information

SSA did not create an electronic version of Form SSA-3830 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 28,125 respondents complete the form. This is less than the GPEA cut-off of 50,000.

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. Consequences of Not Collecting Information or Collecting it Less Frequently

If we did not use Form SSA-3830, non-standardized field office requests for medical information would vary, resulting in longer or shorter requests from hospital to hospital. This would be less efficient, less reliable, and less clear for purposes of quality assurance and other reviews. Because we collect this information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to prevent 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 September 19, 2017, at 82 FR 43804, and we received no public comments. The 30-day FRN published on December 5, 2017 at 82 FR 57520. If we receive any comments in response to this Notice, we will forward them to OMB.

9. Payment of 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 Total Annual Burden (hours)
SSA-3380	28,125	1	15	7,031

We based these figures on our current management inforamtion data. The total burden for this ICR is 7,031 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents

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

14. Annual Cost to the Federal Government

The annual cost to the Federal Government is approximately $43,131. This estimate accounts for the cost for the following areas: (1) designing, printing, and distributing the form; and (2) SSA employee information collection and processing time.

15. Program Changes or Adjustments to the Information Collection Request

There are no chances 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

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

18. Exception 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).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

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