SUPPORTING STATEMENT FOR FORM SSA-3380-BK
FUNCTION REPORT – ADULT THIRD PARTY
20 CFR 404.1512 and 416.912
OMB No. 0960-0635
1. Sections 205(a), 223(d)(5)(A), 1631(d)(1), and 1631(e)(1) of the Social Security Act (the Act) require claimants for Social Security disability benefits to provide medical and other evidence of their disability, with evidence requirements to be established by the Commissioner of Social Security. These sections of the Act also grant the Social Security Administration (SSA) the authority to establish procedures for collecting and verifying this evidence. 20 CFR 404.1512 and 416.912 require claimants to provide the following information: evidence of age, education and training, work experience, daily activities, efforts to work, and any other evidence demonstrating how their ability to work is impacted by their impairment. Form SSA-3380-BK is designed to collect this evidentiary information.
Form SSA-3380-BK is used to collect the types of evidence cited above. This form is completed by a third party, i.e., someone who is familiar with the claimant, the claimant’s impairment, and the limitations to the claimant’s ability to function imposed by the impairment. The information on the SSA-3380-BK is used by the State disability determination services (DDS) evaluators as one of the evidentiary sources used in the initial disability evaluation process. Respondents are third parties familiar with the claimant’s functional limitations (or lack thereof).
Form SSA-3380-BK has not currently been made available in an electronic format under
the Agency’s Government Paperwork Elimination Act plan because SSA has had to
devote its limited resources to other, more urgent electronic projects, such as the new
Medicare Part D online application. However, SSA plans to evaluate this form for
electronic conversion within the next few years.
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. If the information was not collected, the DDSs would have no means of collecting evidentiary information about a claimant’s impairment from a third party familiar with the claimant. This lack of information could prevent the DDSs from making an accurate disability determination. Since the information is only completed once for an initial application and when an appeal is filed, the information cannot be collected less frequently. 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 January 7, 2008, at
73 FR 1253, and SSA received no public comments. The second Notice was published on April 21, 2008 at 73 FR 21400, and there have been no outside consultations with members of the public.
9. SSA provides no payment or gifts to the respondents.
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. The information collection does not contain any questions of a sensitive nature.
12. Approximately 1,000,000 respondents take 60 minutes to complete form SSA-3380-BK each year. Therefore, the total annual burden is 1,000,000 hours. The total burden is reflected as burden hours, and no separate cost burden has been calculated. Respondents may be individuals or private sector. Because we have no programmatic need to know how many respondents are in these two categories, we can only provide an estimate. Therefore, we estimate that 500,000 respondents are individuals and 500,000 respondents are private sector.
13. There is no known cost burden to the respondents.
14. The annual cost to the Federal Government is approximately $13,860,000. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
15. There are no changes in the public reporting burden. However, we needed to create a second IC to show the two different types of respondents (500,000 Individuals and 500,000 Private Sector respondents). Because we added the second IC, ROCIS denotes a change in the burden.
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 1320.8(b)(3).
B. Collections of Information Employing Statistical Methods
Statistical methods are not used for this information collection.
SSA-3380-BK
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR FORM SSA-3380-BK |
| Author | 654350 |
| Last Modified By | 177717 |
| File Modified | 2008-05-08 |
| File Created | 2007-06-25 |