Supporting Statement - 0635 (Final)

Supporting Statement for Form SSA-3380-BK

Function Report – Adult Third Party

20 CFR 404.1512, 404.1564, 416.912, and 416.964

OMB No. 0960-0635

A. Justification

1. Introduction/Authoring Laws and Regulations

Sections 205(a), 223(d)(5)(A), 1631(d)(1), and 1631(e)(1) of the Social Security Act (the Act) require individuals receiving or applying for Social Security disability benefits to provide medical and other evidence of their disability. These sections of the Act also grant the Social Security Administration (SSA) the authority to establish procedures for collecting and verifying this evidence. In our regulations, 20 CFR 404.1512 and 416.912 provide detailed requirements for the types of evidence Social Security disability claimants and beneficiaries must provide showing how their impairments affect their ability to work (e.g., evidence of age; education and training; work experience; daily activities; efforts to work). SSA uses Form SSA-3380, Function Report Adult-Third Party, to collect the information for adult disability cases.

2. Description of Collection

Individuals receiving or applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) provide SSA with medical evidence and other proof SSA requires to prove their disability. SSA, and Disability Determination Services (DDS) on our behalf, collect this information using Form SSA-3380-BK. We use the information to document how claimant’s disabilities affect their ability to function, and to determine eligibility for SSI and SSDI claims. The respondents are third parties familiar with the functional limitations (or lack thereof) of claimants who apply for SSI and SSDI benefits.

2. Use of Information Technology to Collect the Information

Form SSA-3380 is available as a fillable PDF on SSA’s website, which the respondent completes, prints, and mails to SSA. The DDS also mails the form to the respondent to complete and return. This collection does not currently have a fully public-facing Internet version, as we prioritized other information collections for full electronic conversions. Given that IT Mod programming is an ongoing, dynamic project, we cannot provide specific timelines for when we will be able to make any particular ICR available via Internet web-based application.  We will ultimately convert most existing ICRs to full electronic versions depending on how they fall within our overall IT Mod schema, but this may be unconnected to the PRA approval lifecycle.  In the interim, we evaluated this collection for conversion to a submittable PDF and intend to make this conversion within the next 3-6 years. Once we have the submittable PDF ready for implementation, we will submit a Change Request to OMB for prior approval.

2. 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 SSA did not collect this information, we would be unable to adjudicate many new claims for disability benefits or make determinations on continuing eligibility for benefits, leaving us unable to fulfill our mandate to make payments to those who are disabled. Because we ask the respondents to complete the form only once for an initial adult claim for benefits and occasionally again in the case of a continuing disability review or appeal, we cannot collect the information less frequently.

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 August 20, 2021, at

86 FR 46897, and we received no public comments. The 30-day FRN published on October 26, 2021 at 86 FR 59262. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.

8. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

8. 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.

8. Justification for Sensitive Questions

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

8. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollar)*	Total Annual Opportunity Cost (dollars)**
SSA-3380-BK	709,700	1	61	721,528	$27.07*	$19,531,763**

* We based this figure on the average DI payments based on SSA's current FY 2021 data (https://www.ssa.gov/legislation/2021FactSheet.pdf) and on the average U.S. worker’s hourly wages, as reported by Bureau of Labor Statistics data (https://www.bls.gov/oes/current/oes_nat.htm#00-0000).

** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection.  Per our management information data, we believe that the average time in minutes listed in the chart above accurately shows the average burden per response for reading the instructions, gathering the facts, and answering the questions. Based on our current management information data, the current burden information we provided is accurate. The total burden for this ICR is 721,528 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $19,531,763. SSA does not charge respondents to complete our applications.

13. Annual Cost to the Respondents (Other)

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

14. Annual Cost to Federal Government

The annual cost to the Federal Government is approximately $15,536,687. This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars*
Designing and Printing the Form	Design Cost + Printing Cost	$1,684
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$0*
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-11 employee x # of responses x processing time	$15,531,763
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0*
Systems Development, Updating, and Maintenance	GS-9 employee x man hours for development, updating, maintenance	$3,240
Quantifiable IT Costs	Any additional IT costs	$0*
Total		$15,536,687

* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have.  First, since we work with almost every US citizen, we often do bulk mailings, and cannot track the cost for a single mailing.  In addition, it is difficult for us to break down the cost for processing a single form, as field office and State Disability Determination Services staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent.  As well, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based the field office employee (GS-9) who completes this form for these calculations. 

However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection Request

There are no changes to the public reporting burden. We have not changed the time estimate for this collection, nor have we significantly changed the form. Consequently, the average burden per response remains the same.

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 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. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements in

5 CFR 1320.9 and related provisions in 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.