Function Report - Child
(Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th
Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday)
Revision of a currently approved collection
No
Regular
12/13/2024
Requested
Previously Approved
36 Months From Approved
12/31/2024
524,762
579,000
795,890
221,950
0
0
As part of SSA’s disability
determination process, we use Forms SSA-3375-BK through SSA-3379-BK
to request information from a child’s parent or guardian for
children applying for Supplemental Security Income (SSI). The five
different versions of the form contain questions about the child’s
day-to-day functioning appropriate to a particular age group; thus,
respondents use only one version of the form for each child. The
adjudicative team (disability examiners and medical or
psychological consultants) of State disability determination
services offices collect the information on the appropriate version
of this form (in conjunction with medical and other evidence) to
form a complete picture of the children’s ability to function and
their impairment-related limitations. The adjudicative team uses
the completed profile to determine: (1) if each child’s
impairment(s) results in marked and severe functional limitations;
and (2) whether each child is disabled. The respondents are parents
and guardians of child applicants for SSI.
US Code:
42
USC 1382c Name of Law: Social Security Act
US Code: 42
USC 423 Name of Law: Social Security Act
US Code: 42
USC 1383 Name of Law: Social Security Act
When we last cleared this
information collection in 2021, the burden was 193,000 hours.
However, we are currently reporting a burden of 174,921 hours. This
change stems from a decrease in the number of responses from
579,000 to 524,762. There is no change to the burden time per
response. Although the number of responses changed, SSA did not
take any actions to cause this change. These figures represent
current Management Information data. As mentioned above, SSA is
unable to breakdown the method by which the respondents complete
the (whether it was completed electronically via the Intranet;
through an in-office or telephone appointment; or if it was a paper
version submitted to the FO or DDS upon completion, which was then
scanned into the electronic file. Therefore, unlike the information
collection in 2021, we are not able to precisely predict how many
respondents physically traveled to the FO. At the prior information
collection for this form (2021), we determined that approximately
10% of respondents visited the FO to submit a paper version of the
form, relevant to the child’s age. Although we cannot provide exact
data on this scope, we predict that 15% of respondents spent time
traveling to/from the FO, which indicates 39,358 hours of travel
time. * Note: The total burden reflected in ROCIS is 795,890, while
the burden cited in #12 of the Supporting Statement is 174,921.
This discrepancy is because the ROCIS burden reflects the following
components: field office waiting time + a rough estimate of a
30-minute, one-way, drive burden + learning costs. In contrast, the
chart in #12 of the Supporting Statement reflects actual
burden.
$5,793,080
No
Yes
Yes
No
No
No
No
Faye Lipsky 410 965-8783
faye.lipsky@ssa.gov
No
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:
(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;
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.
Form SSA-3375-BK Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview
Supporting Statement - 0542 (Final).docx
Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview