Addendum to Supporting Statement 0960-0144

Addendum to the Supporting Statement for 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), and 416.1540(b)(4)

OMB No. 0960-0144

Background

OMB placed the following Terms of Clearance on this Information Collection when they last approved it on 06/21/2022: Prior to re-submission of this information collection, SSA will evaluate it for consistency with OMB's memo M-22-10 and discuss its evaluation with OMB. SSA will also ensure it augments its federal register postings with other public consultation mechanisms as described in M-22-10.

• SSA evaluated the form for consistency with OMB’s memo M-22-10. SSA was unable to meet with OMB, due to OMB’s scheduling conflicts.

SSA is revising the SSA-3441 (Disability Report-Appeal) to improve its readability and usability, and to format it for consistency with other forms, including recent revisions to

SSA-3368 (Adult Disability Report) and SSA-454 (Continuing Disability Review Report). We will make conforming changes to (a) the screens the field office use when assisting claimants in completing the form and (b) the screens that claimants use when submitting the form via the internet

Revision to the Collection Instrument

• Change #1: PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT

Old language: This report is used to update your information for your disability appeal. Completing this report accurately helps us process your claim. Please complete as much of this report as you can.

New language; You can get help from other people, such as a friend or family member. Please do not ask your healthcare provider to complete this report. If you cannot complete this report, you may contact us at 1-800-772-1213 (TTY 1-800-328-0778). A Social Security Representative will assist you. Have the information available from the bulleted items below when you call us. If you have an appointment, have the information available, or the completed report ready when we contact you. If you cannot speak or understand English, we will provide an interpreter free of charge.

Justification #1: We are revising to ensure an individual knows how to contact SSA if they need assistance; they are aware we provide interpreters if needed, and has a guide about which information they need to provide to complete the form.

• Change #2 We are revising the language in the instructions on page 1-2 under the heading “If You Need Help:

Old language: You can get help from other people, such as a friend or family member. Please do not ask your healthcare provider to complete this report. If you cannot complete this report, you may contact us at 1-800-772-1213 (TTY 1-800-328-0778). A Social Security Representative will assist you. Have the information available from the bulleted items below when you call us. If you have an appointment, have the information available, or the completed report ready when we contact you. If you cannot speak or understand English, we will provide an interpreter free of charge.

New Language: You can get help from other people, such as a friend or family member. Please do not ask your healthcare provider to complete this report. If you cannot complete this report, you may contact us at 1-800-772-1213 (TTY 1-800-328-0778). A Social Security Representative will assist you. Have the information available from the bulleted items below when you call us. If you have an appointment, have the information available, or the completed report ready when we contact you. If you cannot speak or understand English, we will provide an interpreter free of charge.

Justification #2: We are making the above changes to the form’s instructions to improve their clarity, and to align them with other forms.

• Change #3: We are revising the paragraph under the heading “Your Medical Records” and moving it from page 2 to page 1.

Old language: If you have any medical records that you have not given to us, send or bring them to our office with this completed report. Please tell us if you want us to return them to you. If you are having an interview in our office, bring your medical records, your prescription medicine containers (if available), and this completed report with you

New language: YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS. If you have consented to us obtaining medical records from your providers, we will request your records directly from them. The information that you give us on this report tells us where to request your medical and other records

Justification 3: We are making revisions to form’s instructions to improve their clarity, and to align them with other forms.

• Change #4: We are revising the heading to “What you need to complete this report” and adding items needed to the bulleted list.”

Old language: HOW TO COMPLETE THIS REPORT If you have Internet access, you may be able to complete this report online at www.ssa.gov/disability/appeal. If you complete this report on paper: • Print or write clearly. • Include a ZIP or postal code with each address. • Provide complete phone numbers, including area code. If a phone number is outside the United States, also provide International Direct Dialing (IDD) code and country code. • If you cannot remember the names and addresses of your health care providers, you may be able to get that information from the telephone book, Internet, medical bills, prescriptions, or prescription medicine containers. • ANSWER EVERY QUESTION, unless the report indicates otherwise. You can write "don't know," or "none," or "does not apply" if you need to. • If you need more space to answer any question, please use the REMARKS section on the last page, SECTION 10. Include the number of the question you are answering.

New Language: WHAT YOU NEED TO COMPLETE THIS REPORT

• Names, addresses, and phone numbers of two people (other than your doctors) we can contact who know about your medical condition(s) and can help with your case, if needed.

• Information about any education since you last told us about your education.

• Any prescription or non-prescription medicines you take.

• Names, address, and phone numbers of any healthcare providers and information about the medical treatment you received, or testing performed since you last told us about your medical treatment.

• If you cannot remember the information about your healthcare providers, the treatment you received, or the testing performed, you may be able to get that information from the telephone book, Internet, online medical chart, medical bills, prescriptions, or prescription medicine containers.

• If you cannot remember the exact dates, provide the closet date you can remember.

• Name(s) of organization(s) we can contact that would have medical information about your condition(s) since you last told us about your other medical information, such as Department of Veterans Affairs, social services agencies, vocational rehabilitation agencies, welfare agencies, attorneys, prisons, workers’ compensation, and insurance companies who have paid you disability benefits.

• Information about any vocational rehabilitation, employment, or other support services since you last told us about your support services.

• ANSWER EVERY QUESTION unless this report indicates otherwise. Provide as much details as possible. If you do not know an answer, or the answer is “none” or “does not apply,” please write "don't know," or "none," or "does not apply."

• Be sure to explain an answer if the question asks for an explanation, or if you want to provide additional information. If you need more space to answer any question, use Section 10 - Remarks.

• Change #5: We are adding a penalty of perjury statement on page 3 just prior to Section1.

Justification #5: We are making this change for legal clarification purposes. This update is consistent with the SSA-3368 and recent revisions to the SSA-3369.

• Change #6: We are revising the language on page 3 above Section 1, and moving the language under the Section 1 Information about You

Old language: If you are filling out this report for someone else, please provide information about him or her. When a question refers to "you", "your," it refers to the person who is applying for disability benefits.

New language: When a question refers to “you” or “your,” it refers to the person applying for disability benefits. If you are completing this report for someone else, please provide information about them

Justification #6: We are changing the pronouns we use to non-gendered pronouns on page 3 to align with Executive Order (EO) 13988, Preventing and Combating Discrimination on the Basis of Gender Identify and Sexual Orientation. These changes are consistent with recent revisions to other forms.

• Change #7: We are making the following on page 4, Section 1:

• 1. We are revising the title of the section to “Information About You.”

• 2. We are revising the sentence to include “other names” you may have used in medical or educational records and moving it from 4.A. to 1.C.

• 3. We are adding a statement about providing a phone number where we can leave a message in 1.F.

• 4. We are combining our request for a primary and secondary phone number in 1.F.

Justification #7: We are updating and reordering the questions to improve accuracy and for consistency with other forms.

• Change #8: We are making the following changes on page 4, Section 2-Contacts:

• 1. We are revising the introduction to “Is there someone we can contact who can help with your claim, if needed,” including examples, and adding check boxes for “yes” or “no.”

  • For “yes,” we are adding text about providing two contacts other than a doctor who know about your medical conditions and can help us reach you.

• For “no,” we are adding text that recommends providing us with at least one contact.

• 2. We are replacing “you” with “Person in 1.A.” in question 2.B.

• 3. We are moving the question about who is completing the form in 2.F through 2.J to the end of the form in new Section 11.

• 4. We are adding an additional contact to 2.F. through 2.J. and requesting the same information as 2.A. through 2.E

Justification #8 : We are adding this information for consistency with other forms, and to improve accuracy and usability. We are adding the additional contact to conform to the revised failure to cooperate-insufficient evidence policy.¹ Under our current policy, we require field office technicians to collect the additional third-party contact in the Remarks section. This change will streamline the collection of this information for the respondents.

• Change #9: We are making the following changes on page 4, Section 3:

• 1. We are revising the title of the section to “Medical Information.”

• 2. We are changing the date format to MM/DD/YYYY in questions 3.A and 3.B.

• 3. We are changing the question to “Describe the change(s) in detail:” in 3.A.

• 4. We are changing the question to “Describe your new medical condition(s) in detail:” in 3.B.

Justification #9: We are making these additional changes for consistency with other forms, and to improve accuracy and usability.

• Change #10: We are making the following changes on page 7, Section 4 - Medical Treatment:

• 1. We moved the question about other names used in medical and educational records from 4.A. to 1.C (as noted in Change #5)

• 2. We streamlined the question in 4.A. (formerly 4.B.) and removed 4.C.

• 3. We added the statement “You may find this information on medical bills, online medical chart, or the Internet.”

• 4. We are moving the treatment tables (formerly in 4.D) to questions 4.B.

• 5. We are adding the text “name of facility or office” and “name of the healthcare provider that treated you.”

• 6. We are removing the patient ID# field.

• 7. We are removing specific questions about dates of treatment (e.g., clinic, emergency room, overnight hospital stays).

• 8. We are revising the question about dates the respondent was seen by a healthcare provider to “date first seen,” “date last seen,” and “date of next appointment,” and adding “if known.”

• 9. We are changing the date format to MM/YYYY.

• 10. We are removing the question about what treatment you received.

• 12. We are removing the question about tests the provider performed or sent you to, or scheduled you to take, and the check boxes, and moving the medical test table to question 4.B.

• 13. We are removing tests and check boxes from the medical treatment table (discussed in Change 15) and moving them to question 4.B.

• 14. We are adding “Psychological/IQ test” to the table.

• 15. We are adding a “name of healthcare provider” column to the table.

• 16. We are changing the formatting for date of test to MM/YYYY.

Justification #10: We are making these additional changes for consistency with other forms, and to improve accuracy and usability.

• Change #11: We are adding examples to page 10, Section 5- Other Medical Information to include Department of Veterans Affairs, social service agencies, vocational rehabilitation agencies, welfare agencies, attorneys, prisons.

Justification #11: We are including the additional examples to help the claimant complete the other medical information section and for consistency with other forms.

• Change #12: We are adding examples to page 11, Section 7- Activities to include chores and preparing meals.

Justification #12: We included the additional examples to help the claimant complete the activities section and for consistency with other forms.

• Change #13: We are adding examples to page 12,Section 8- Work and Education to include GED classes, specialized job training, trade school, vocational school, college classes or online education.

Justification #13: We included the additional examples to help the claimant complete the work and education section and for consistency with other form.

• Change #14: We are making the following changes page 13, Section 9 - Support Services: to include Individualized Education Plan (IEP), Individualized work plan, including ticket to work program, plan to achieve self-support (PASS), and an individualized plan for employment with a vocational rehabilitation agency or any other organization.

Justification #14: We included the additional examples to help the claimant complete the support services section and for consistency with other forms.

• Change #15: We are adding new instructions to page 13, Section 10 - Remarks.

Justification #15: This update is consistent with recent revisions to the SSA-3368.

• Change #16: We are adding a new section on page 15 to collect the form completer in Section 11- Who is completing this report. The options for the response are: The person listed in 1.A., 2.A., 2.F., or Someone else and then we ask the person to complete the contact information below.

Justification #16: We grouped all contact information together to provide a better flow for the claimant. It allows for easy reference to the contact in 2.A, who may also be the form completer.

1 SSA’s failure to cooperate-insufficient evidence policy (FTC) describes what SSA requires adjudicators to do when a claimant does not comply with an initial request for evidence or action, or an initial notice of a consultative examination (CE) appointment. FTC procedures apply to initial and reconsideration level claims.