Function Report - Adult Third Party, 20 CFR 404.1512 and 416.912

Forms and Documents

Document Name	Status
Form SSA-3380-BK Function Report - Adult Third Party, 20 CFR 404.1512 and 416.912 Form and Instruction	Modified
RE OMB Comments - Function Report Adult Third Party (0960-0635).htm Supplementary Document	2006-10-16
Supporting Statement--0635[1].doc Supporting Statement A	2006-08-17
Addendum--0635(R).doc Supplementary Document	2006-08-17

IC Document Collections

IC ID	Document Title	Status
9663	Function Report - Adult Third Party, 20 CFR 404.1512 and 416.912 Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0635	ICR Reference No: 200608-0960-004
Status: Historical Active	Previous ICR Reference No: 200407-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Function Report - Adult Third Party, 20 CFR 404.1512 and 416.912
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/17/2006
	Date Received in OIRA: 08/18/2006
Terms of Clearance: This form is a potential electronic candidate under SSA's GPEA implementation plan. SSA plans to evaluate this form for electronic conversion within the next few years. OMB approves this form with the understanding that upon resubmission of this form for OMB approval, SSA will have completed this evaluation and will provide OMB with a full report of the results of the evaluation.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2009	36 Months From Approved	08/31/2007
Responses	1,000,000	0	1,000,000
Time Burden (Hours)	1,000,000	0	500,000
Cost Burden (Dollars)	0	0	0

---

Abstract: The information collected on the SSA-3380-BK is needed to make determinations on SSI and SSDI disability claims. This information is necessary for case development and adjudication, and is used by State Disability Determination Services evaluators as an evidentiary source used in the disability evaluation process. The respondents are third parties familiar with the functional limitations (or lack thereof) of claimants who apply for Social Security benefits and Supplemental Security Income disability payments.

---

Authorizing Statute(s): US Code: 42 USC 423 Name of Law: null
   US Code: 42 USC 1383 Name of Law: null
   US Code: 42 USC 405 Name of Law: null
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 30464	05/26/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 43270	07/31/2006
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Function Report - Adult Third Party, 20 CFR 404.1512 and 416.912	SSA-3380-BK, SSA-3380-BK	Function Report--Adult--Third Party ,   Function Report--Adult--Third Party (Revised Version)

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,000,000	1,000,000	0	0	0	0
Annual Time Burden (Hours)	1,000,000	500,000	0	250,000	250,000	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: We have doubled the estimated burden hours due to the receipt of public comments over the past three years which stated that 30 minutes (our previous estimate of completion time) was not sufficient time to complete the form. We have received no public comments due to the publication of the Federal Register Notices listed above. We are also revising the form to collect information about the functional effects of a claimant's illnesses, injuries, or conditions related to symptoms on their activities and abilities.

---

Annual Cost to Federal Government: $13,860,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/18/2006

---