Supporting Statement--0431

Supporting Statement for Forms SSA-4734-BK and SSA-4734-F4-SUP

Physical Residual Functional Capacity Assessment and

Mental Residual Functional Capacity Assessment

20 CFR 404.1545-.1546 and 416.945-.946

OMB No. 0960-0431

1. Justification

1. Sections 221(a) and 1633 of the Social Security Act require a State Agency to determine on behalf of SSA if an individual is disabled, prior to granting Social Security benefits to that individual. Additionally, 20 CFR 404.1545-.1546 and 416.945-.946 require that the State Agency (called State Disability Determination Services (DDS)) administering the Title II Disability Insurance and Title XVI Supplemental Security Income (SSI) programs evaluate the impact of physical and mental impairments on an individual’s capacity to do and sustain the physical activities and mental demands of work. In accordance with these regulations, the SSA‑4734‑BK (Physical Residual Functional Capacity Assessment) and SSA‑4734‑F4-SUP (Mental Residual Functional Capacity Assessment) are used to collect information to determine the residual functional capacity of an individual with a physical and/or mental impairment.

2. The Social Security Administration (SSA) needs the information from these forms to assist in the adjudication of disability claims involving physical or mental impairments. The information on the forms is used by the State DDSs (1) to ensure that work-related physical and mental functions are considered and addressed and (2) to evaluate the individual’s remaining capacity to do and sustain the critical activities of work. Approximately 95% of respondents are employees of, or work under contract with, State governments (through State Disability Determination Services) and 5% are Federal employees (SSA doctors).

3. The SSA-4734-BK and SSA-4734-F4-SUP are scheduled for complete electronic implementation. Currently, these forms are available online in a PDF format that can be printed, completed manually by a medical or psychological consultant (MC/PC) or other program doctor, and then scanned into a claimant’s electronic disability folder. In approximately 2 years, these forms will be part of a completely electronic process in which respondents will be able to complete and transmit them directly into electronic disability claim folders. At this time, the process has not been implemented.

4. The nature of the information being collected and the manner in which it is collected preclude duplication. There is no other collection instrument used by SSA that collects data similar to that collected here.

5. This collection does not have a significant impact on a substantial number of small businesses or other small entities.

6. Generally, the MC/PC or other program doctor completes the appropriate form (SSA‑4734-BK and SSA-4734-F4-SUP, respectively) only once, when an individual first applies for benefits. This information cannot be collected less frequently than once in claims. Failure to complete these forms would result in an inability to determine an individual’s residual functional capacity and ability to work; therefore, it would be impossible to determine whether the individual is disabled under the Social Security Act and implementing regulations. There are no technical or legal obstacles that prevent burden reduction.

7. There are no special circumstances that would cause this information collection to be conducted in a manner that is not consistent with 5 CFR 1320.5.

8. The 60-day advance Federal Register Notice was published on December 15, 2006 at 71 FR 75607, and SSA has received no public comments. The second Notice was published on February 14, 2007, at 72 FR 7107. There have been no outside consultations with members of the public.

9. SSA pays MCs/PCs and other program doctors $67.32 an hour to evaluate disability claims and to complete these forms to document the results of their evaluations.

10. The information requested is protected and held confidential 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. These information collections ask questions that may be perceived as sensitive, since they relate to an individual’s physical and mental disabilities. However, these questions are necessary in order to determine whether the individual is disabled under the Social Security Act.

12. Each year approximately 1,608,844 respondents complete form SSA-4734-BK, and 788,802 respondents complete form SSA-4734-F4-SUP, for a total of 2,397,646 respondents. The estimated time to complete each form is 20 minutes. The total burden for forms SSA‑4734‑BK and SSA-4734-F4-SUP is, therefore, 799,215 hours. These figures are based on a 1% reduction in the number of total dispositions between 2003 and 2005. FY 2006 was an anomaly in that DDSs stopped processing Continuing Disability Review caseloads, temporarily causing a production decrease of 9%. The total burden is reflected as burden hours, and no separate cost burden has been calculated.

13. There is no cost burden to the respondents because SSA pays them.

14. The annual cost to the Federal Government is approximately $76,181,186. This figure is based on (a) 799,215 hours of response time at $67.32 per hour to complete 2,397,646 responses (=$53,803,154), plus (b) a cost of approximately $22,378,032.60 for printing and distributing the collection instruments.

15. The public reporting burden of 799,215 hours represents a 1% decrease in burden hours. This burden change is due to a decrease in the number of case dispositions since the last clearance in 2003.

16. The results of the information collection will not be published.

17. OMB has granted SSA an exemption from the requirement that the expiration date for OMB approval be printed on its program forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB approval. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). This exemption was granted so that otherwise useable editions of forms would not be taken out of circulation because the expiration date had been reached. In addition, Government waste has been avoided because stocks of forms will not have to be destroyed and reprinted.

18. SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.89(b)(3).

2. Collections of Information Employing Statistical Methods

Statistical methods are not used for this information collection.

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