OMBSupportingStatementFunctionReports.053107

4

June 2007

Supporting Statement for Function Reports - Child

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

20 CFR 416.912

OMB No. 0960-0542

A. Justification

1. Authoring Laws and Regulations - Section 1614(a)(3)(A) of the Social Security Act (the Act), as amended, provides that a child under age 18 is considered disabled under title XVI of the Act if he or she “…has a medically determinable physical or mental impairment, which results in marked and severe functional limitations….” The authority to prescribe requirements for the collection of information to help determine a child’s eligibility under title XVI is in §§1614 (a) (3) (H) (i), 223(d) (5) (A), and 1631(e) (1) (A) of the Act, and in 20 CFR 416.912.

In order to assess a child claimant’s functional limitations, the Agency must collect information from those in a position to know of the child’s daily functioning, including the child’s parent(s) or other primary caregiver(s) (hereinafter referred to just as “parent”). This is discussed in 20 CFR § 416.924a (a) (2) of the final childhood disability regulations published on September 11, 2000.

Forms SSA-3375-BK through SSA-3379-BK request information from the child’s parent about the child’s day-to-day functioning. The five different versions of the form contain questions about functioning appropriate to a particular age group; thus, only one version is used for each particular child.

2. How, By Whom, and For What Purpose the Information Is To Be Used - The adjudicative team (disability examiners and medical/psychological consultants) of the State’s disability determination services (DDS) uses the information gathered on the appropriate version of this form (in conjunction with medical and other evidence) to form a complete picture of the child’s ability to function and of his/her impairment-related limitations. When this profile of the child’s functioning is complete, the adjudicative team determines whether or not the child’s impairment(s) results in marked and severe functional limitations, and, therefore, whether or not the child is disabled.

3. Use of Information Technology To Collect the Information - When these forms are completed in an interview setting in the field office, the questions on these forms are pulled up on the interviewer’s computer screen, and the interviewer keys the answers directly on the automated form. In many instances, however, parents fill out the forms at home. The information in this collection is gathered on special forms that contain bar code information. At this time we lack sufficient technology to transmit these forms over the Internet in such a way that the encoded information will still be readable by our scanners. Therefore, we cannot make this collection electronic at this time. (It should be noted that the application form for SSI Childhood Disability Benefits, the T-16, is not on SSA’s Internet site, nor are there any current plans to include that form on the Internet. This is not necessarily inappropriate, since the SSI population probably has less access to the Internet than do other segments of the population.)

4. Why Duplicate Information Cannot Be Used - Development of these forms was coordinated with the development and revision of other forms used in childhood disability cases, e.g., Forms SSA-3820 and SSA-3881, to avoid duplication. There is no similar information about a child’s daily functioning already available that could be used in place of information from the child’s parent – no source has more information about the child’s daily functioning. There are, of course, other sources of information about a child’s functioning including school teachers, in particular, and we collect information from all other such sources. However, the regulations require us to form a complete picture of a child’s ability to function, and this would be impossible without consideration of the child’s functioning in the home setting.

5. How Burden on Small Respondents Is Minimized - Collection of this information does not involve small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting It Less Frequently - In a given claim the information will be collected once, as part of the initial claims process. Updated information might be collected if and when a continuing disability review is conducted regarding a child who is already receiving benefits. If this information were not collected, SSA’s ability to make accurate and supportable disability determinations in childhood disability cases would be significantly compromised. However, there are no technical or legal obstacles that prevent burden reduction.

7. Special Circumstances That Need To Be Explained - 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. Solicitation of Public Comment and Other Consultations with the Public - The 60-day advance Federal Register Notice was published on June 13, 2007 at 72 FR 32697, and SSA received no public comments. The second Notice was published on August 20, 2007 at 72 FR 46529, and there were no outside consultations with members of the public.

9. Payment or Gifts to Respondents - SSA provides no payment or gifts to the respondents.

10. Assurances of Confidentiality - The information requested on this form will be protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552a (Privacy Act), and OMB Circular No. A-130.

11. Justification for Sensitive Questions - This form does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden - When initially applying for SSI benefits on behalf of a child, each respondent (Individuals/Households only) will be requested to provide one response to the Function Report form that is appropriate to the child’s age. An additional response may be needed if and when a continuing disability review (CDR) of the child’s case is conducted. Based on case counts as reported for 2004, 2005, and 2006 in the April 2007 draft of the 2007 SSI Report to Congress, Forms SSA-3375, 3376, 3377, 3378 and 3379 will be used by approximately 550,000 respondents annually in initial and continuing disability cases. We expect that it will take around 20 minutes to fill out the form appropriate for a particular child’s age, so the total annual burden will be 183,333 hours. We cannot translate this into a meaningful dollar figure.

13. Annual Cost to the Respondents - There is no known cost burden to the respondents.

14. Annual Cost to Federal Government - Estimated annual cost to the Federal Government is approximately $22,022,000. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information on all five Function Report forms.

15. Program Changes or Adjustments to the Information Collection Budget - The change in the number of respondents and the associated hour burden (from 650,000 respondents in the previous clearance request to 550,000 in this request) is based on data prepared for the April 2007 draft of the 2007 SSI Report to Congress, which is pending publication. This change in the public reporting burden was caused by a decrease in the number of respondents completing the forms. The lower number of respondents was not caused by any program change on the part of SSA, but rather was due to attrition.

16. Plan for Publication of Results of Information Collection - The results of the information collection will not be published.

17. Request Not To Display OMB Expiration Date - 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 clearance. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). This exemption was granted so that otherwise usable 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. 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

Statistical methods are not used for this information collection.