Supporting Statement - 0542 (Final)

Supporting Statement for Function Reports - Child

Forms SSA-3375, SSA-3376, SSA-3377, SSA-3378, and SSA-3379

20 CFR 416.912 and 416.924a(a)(2)

OMB No. 0960-0542

A. Justification

1. Introduction/Authoring Laws and Regulations

Section 1614(a)(3)(A) of the Social Security Act (Act), mandates the Social Security Administration (SSA) consider children disabled under Title XVI of the Act if they have “a medically determinable physical or mental impairment, which results in marked and severe functional limitations….” Sections 1614(a)(3)(H)(i) and 1631(e)(1)(A) of the Act and 20 CFR 416.912 of the Code of Federal Regulations (Code) grant SSA the authority to establish requirements for the collection of information to help determine a child’s eligibility under Title XVI. We collect information from people who know the child’s daily functioning, including the child’s parent(s) or other primary caregiver(s) (hereinafter, referred to as “parent”), to assess the child’s functional limitations, as discussed in 20 CFR 416.924a(a)(2) of the Code.

2. Description of Collection

As part of SSA’s Supplemental Security Income (SSI) disability determination process, we use Forms SSA-3375-BK through SSA-3379-BK to request information from a child’s "caregiver”, meaning someone who has a close, familial-type relationship with the child, such as a parent or guardian, for children applying for SSI. SSA developed these forms in the late 1990s, as part of an inter-component workgroup. Using input from regional offices, policy experts, and stakeholders, the workgroup developed the questions within each form based on SSI policy and available medical and scientific information. The purpose of the forms was to create national uniformity in information collected about children under SSI. The adjudication steps are periodically reviewed by subject matter experts in the Office of Medical Policy to monitor and ensure consistency with changes or advancements in relevant scientific fields.

For childhood disability claims, the respondent usually obtains and completes the form at the time of filing/when the interview is conducted (whether it be in person or via phone). However, there are times in which the adjudicative team will send out the form via mail for the respondent to complete and returned via mail or fax, or the examiner may take the information over the phone and submit the form electronically into the file. The adjudicative team does this in the event that the form is not in the electronic file when they receive the case, the form was inaccurately completed at the time of filing, or the respondent failed to provide or elaborate on the appropriate details necessary to assist with case adjudication regarding functioning. The respondents generally answer the questions on their own whether it be through personal interview (electronic submission) or handwritten and returned to the FO or DDS.

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 and/or psychological consultants) of State Disability Determination Services (DDS) offices collect the information on the age‑appropriate version of Forms SSA-3375-BK through SSA-3379-BK, in conjunction with medical and other evidence, to form a comprehensive depiction of the child’s functioning and any impairment-related limitations. The adjudicative team uses the completed form to determine: (1) if each child’s impairment(s) results in marked and severe functional limitations; and (2) whether each child is disabled.

We identified the following psychological cost based on the requirements for this information collection:

• Psychological Cost:

  • Requirement for the Program: these forms require the respondent to provide personal information about the child’s functioning, capabilities, and limitations during the disability case process.

• Psychological Cost: Despite the value of the information collected from the form in the adjudicative process, the respondent may perceive the information requested to be unduly invasive.

We understand these psychological costs may cause respondents to delay their completion of the information collection or cause them to abandon the information collection entirely. However, we require full completion of this collection to receive benefits. Therefore, we have taken this potential psychological cost into account when calculating our burden in #12 below.

The respondents are caregivers, including parents, guardians, and/or any other individual who has a close, familial type relationship with the child applying for SSI.

3. Use of Information Technology To Collect the Information

Respondents can respond to this information collection via an in-person interview setting in a Field Office (FO) or via telephone interview with a FO representative and/or state Disability Determination Services adjudicator. This is the case for most respondents. However, in some instances, this information is obtained when a parent and/or caregiver completes the fillable form at home and physically brings it to the FO or returns the form via mail to the FO or DDS. The paper versions of the form are then eventually uploaded into the electronic folder. We estimate this happens about 15% of the time.

This information collection does not currently allow for electronic submission or electronic disclosure as described in the Government Paperwork Elimination Act plan. SSA created fillable and printable PDF Internet versions of the 5 Forms (Forms SSA-3375 through SSA-3379) through our internal Electronic Disability Collect System (EDCS). When respondents complete these forms in an interview setting or via telephone, FO and/or DDS personnel enter the information the respondents provide through the EDCS screens, and the information is logged in EDCS and uploaded into the child applicant’s file. The management information (MI) data for this information collection does not allow separation of method by which the data we collect was added into the electronic folder (Intranet vs. paper version), but rather provides the total number of completed SSA-3375 through SSA 3379 forms in FY 2023. In the previous information collection (2021), we estimated that approximately 90% of respondents under this OMB information collection used the electronic EDCS version. It is very likely that this number remains relative to the current information collection and respondents continue to utilize the electronic version via in-person interview or over the phone.

As mentioned above, 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 through our Upload Documents (eSubmit) Portal (OMB No. 0960-0830), 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.

4. Why We Cannot Use Duplicate Information

We coordinated the development and revision of other forms used in childhood disability cases, such as SSA-3820 (OMB No. 0960-0577) and SSA-3881 (OMB No. 0960-0499), to avoid duplication. When initially applying for SSI, the parent or caregiver fills out the SSA-3820, Disability Report – Child (OMB No. 0960‑0577), as well as one of the SSA-3375-BK through SSA-3379-BK (this collection, OMB No. 0960-0542), as relevant to the child’s age. At the time of an initial application, we do not require the respondent to complete the SSA-3881, Questionnaire for Children Claiming SSI Benefits (OMB No. 0960-0499). The SSA-3881 asks for this information when information is not in the case record or additional information is needed to develop a complete picture of a child’s functioning and uses it only to add to the information we collect using Form SSA‑3820.

SSA does not collect any similar information about a child’s daily functioning that we can use in place of information from the child’s parent and/or caregiver. In addition to this information collection and those discussed above during the initial SSI application process, we also collect information about a child’s functioning from teachers, who fill out the SSA-5665 and SSA-5666 (OMB No. 0960-0646). SSA collects this information after the application for disability, when the respondent supplies information about the child’s current school and identity of the child’s teacher(s) and/or educator(s). SSA’s regulations require us to formulate a complete picture of a child’s ability to function, and this would be impossible without consideration of the child’s daily functioning in the home setting, as required by 20 CFR 416.924a.

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

The DDSs collect the information as part of the initial SSI claims process. We will also collect updated information when conducting a continuing disability review (CDR) regarding a child who already receives SSI payments. If the DDSs did not collect this information on our behalf, it would significantly compromise SSA’s ability to make accurate and supportable disability determinations in childhood disability cases. Because we only collect the information on an as needed basis, 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 September 12, 2024, at 89 FR 74351, and we received no public comments. The 30-day FRN published on December 6, 2024, at 89 FR 97155. 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

SSA considers that some respondents may find some of the questions in this information collection sensitive in nature, including personal details about the child’s development and overall functioning. However, we require the information from this collection to assure a complete medical and non-medical record is obtained to fulfill the disability adjudicative process. As stated above, we considered these concerns in our overall burden per response shown in #12 below.

12. Estimates of Public Reporting Burden

SSA calculated the burden below using MI data by estimating the amount of time respondents take to learn about the program; receive notices as needed; read and understand instructions; gather the data and documents needed; answer the questions and complete the information collection instrument; schedule any necessary appointment or required phone call; and wait time to speak with SSA employees (as needed). The chart below shows the current public reporting burden for these forms:

Modality of Completion (paper & Intranet/ electronic versions)	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollars)*	Average Wait Time in Field Office or Teleservice Center (minutes) **	Total Annual Opportunity Cost (dollars)***
SSA-3375	26,864	1	20	8,955	$31.48*	21**	$577,878***
SSA‑3376	53,347	1	20	17,782	$31.48*	21**	$1,147,540***
SSA‑3377	108,745	1	20	36,248	$31.48*	21**	$2,339,247***
SSA‑3378	193,800	1	20	64,600	$31.48*	21**	$4,168,896***
SSA-3379	142,006	1	20	47,335	$31.48*	21**	$3,054,725***
Totals	524,762			174,921			$11,288,286***

* We based this figure by averaging both the hourly average DI payments based on SSA’s current FY data (https://www.ssa.gov/legislation/2024FactSheet.pdf), and 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).

** We based this figure on the average FY 2024 wait times for field offices, based on SSA’s current management information data.

*** 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.

In addition, OMB’s Office of Information and Regulatory Affairs is requiring SSA to use a rough estimate of a 30-minute, one-way, drive time in our calculations of the time burden for this collection. OIRA based their estimation on a spatial analysis of SSA’s current field office locations and the location of the average population centers based on census tract information, which likely represents a 13.97-mile driving distance for one-way travel. SSA is unable to determine how many respondents physically traveled to the FO to complete an electronic version or return a paper version of this form in this information collection, but rather only provides the total number of respondents who completed the form, which is uploaded into the electronic file. At the prior information collection for this form (2021), it was determined that approximately 90% of respondents submitted an electronic version of the form to ECDS, which did not require travel to the FO, but was rather handled at the time of electronic filing over the phone or electronic entry via DDS personnel. It should be noted that the COVID-19 pandemic greatly impacted the disability application process and reduced the footprint of in-person interviews at that time.

With the loosening of COVID-19 pandemic restrictions, it is likely that for this current information collection, more in-person interviews have been conducted and that more than 10% of respondents traveled to the FO to complete the form, whether it was an electronic or paper version. In anticipation that more respondents traveled to the FO in the FY 2023, the chart below depicts an estimated 15% of the respondents traveled to the FO to complete the form:

Total Number of Respondents Who Visit a Field Office	Frequency of Response	Average One-Way Travel Time to a Field Office (minutes)	Estimated Total Travel Time to a Field Office (hours)	Total Annual Opportunity Cost for Travel Time (dollars)****
78,715	1	30	39,358	$881,226****

****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

Per OIRA, we include this travel time burden estimate under the 5 CFR 1320.8(a)(4), which requires us to provide “time, effort, or financial resources expended by persons [for]…transmitting, or otherwise disclosing the information,” as well as 5 CFR 1320.8(b)(3)(iii) which requires us to estimate “the average burden collection…to the extent practicable.” SSA notes that we do not obtain or maintain any data on travel times to a field office, nor do we have any data which shows that the average respondent drives to a field office, rather than using any other mode of transport. SSA also acknowledges that respondents’ mode of travel and, therefore, travel times vary widely dependent on region, mode of travel, and actual proximity to a field office.

NOTE: We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates in the paragraph below.

We calculated the following Learning Cost time burden based on the estimated time and effort we expect respondents will take to learn about this program, its applicability to their circumstances, and to cover any additional research we believe respondents may need to take to understand how to comply with the program requirements (beyond reading the instructions on the collection instrument).

Note: As respondents learn about the disability program and forms SSA-3375 through SSA-3379, whether it be through the internet or via FO representative, we expect the learning cost burden to be low for this information collection. The number depicted below could be less; or larger if the respondent needed to obtain additional information on the information collection being asked.

Total Number of Respondents	Frequency of Response	Estimate Learning Cost (minutes)	Estimated Total Annual Burden (hours)	Total Annual Learning Cost (dollars)**
524,762	1	20	174,921	3,916,482****

*****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

NOTE: We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates.

We believe that 20 minutes accurately shows the average burden per response for learning about this program, reading and understanding instructions, gathering the information needed, answering questions, and completing the information collection instrument, along with scheduling any necessary appointment or phone call and waiting to speak with any SSA or DDS employees (as needed).

The total burden for this collection instrument is 174,921 burden hours, reflecting management information data, including the time and effort we expect respondents will take to complete the form SSA-3375 through SSA-3379, as relevant to the child’s age. This results in an associated theoretical (not actual) opportunity cost financial burden of $13,413,939.  SSA does not charge respondents to complete this form.

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 $5,793,080. 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	$11,806
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-9 employee ($33/hr) x # of responses x processing time	$5,772,382
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	$8,892
Quantifiable IT Costs	Any additional IT costs	$0*
Total		$5,793,080

* 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.  We work with almost every U.S. citizen and oftentimes we do bulk mailing and cannot track the cost for a single mailing. We do not track design costs or upkeep costs (as these are based on employee time and may vary from collection to collection).  Additionally, it is difficult to break down the cost for processing a single from, as FO and state DDSs staff often help respondents fill out several forms at once, and the time it takes to do so can vary. For this information collection we estimate that the form(s) can take approximately 20 minutes to complete but acknowledge that more or less time could be needed based on the amount of information the respondent provides. Because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations. We have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining this information collections.

15. Program Changes or Adjustments to the Information Collection Budget

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.

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 (for example, 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. Exemptions 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 will not use statistical methods for this information collection.