The information collected on form
SSA-3368-BK is needed for the determinations of disability by the
State Disability Determinations Services. This version of the form
will be used in those SSA offices and State DDS offices that are
piloting SSA's reengineered disability system. The information will
be used to develop medical evidence and to assess the alleged
disability. The respondents are applicants for disability
benefits.
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.