Supporting Statement for Form SSA‑3827
Medical Report (Individual with Childhood Impairment)
20 CFR 404.1512-.1515, 416.912-.915, 404.1624, and 416.1024
OMB No. 0960-0102
A. Justification
1. Sections 205(a), 223(d)(5)(A), 1614(a)(3)(H)(i), and 1631(d)(1) of the Social Security Act and sections 20 CFR 404.1512-.1515 and 416.912-.915 of the Code of Federal Regulations (CFR) require an individual applying for Social Security disability benefits to provide medical evidence proving the existence and severity of the impairment. Form SSA-3827, the Medical Report (Individual with Childhood Impairment), is used to document such evidence for disability applicants with childhood impairments (i.e. childhood onset). The respondents are medical professionals associated with the diagnosis or treatment of the benefits applicant, including physicians, hospital directors, and medical records librarians.
2. The Social Security Administration (SSA) uses form SSA-3827 (obtained via the Disability Determination Services/DDSs) to accurate determine if applicants for disability benefits who are claiming a childhood impairment meet the necessary severity and duration requirements for benefits. The form is completed by medical professionals who are familiar with the claimant’s impairment. Thus, it provides disability adjudicators and reviewers with a narrative record and history of the alleged disability, and with the objective medical findings necessary to make a disability determination.
3. Form SSA-3827 is currently available in paper form only. Because many DDSs simply request medical reports instead of using this form, the demand for an electronic SSA-3827 is not high enough to warrant its development. We will re-evaluate the need for an electronic version in the future.
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 significantly impact small businesses or other small entities.
6. If form SSA-3827 were not used, in may cases SSA would 1) be forced to use more costly methods of verifying disability, such as paying for a consultative exam, or 2) be forced to deny disability benefits due to lack of evidence. This could result in a claimant unfairly being denied disability benefits. Because form SSA-3827 is only completed when an initial disability claim is made, it cannot be completed 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 September 20, 2007, at Volume 72 FR at 53803, and SSA received no public comments. The 30-day advance Federal Register Notice was published on November 30, 2007, at 72 FR 67776. SSA will forward any comments it receives in response to the 30-day Notice to OMB. There have been no outside consultations with members of the public.
9. The medical sources completing form SSA-3827 are compensated for their time in accordance with the regulations at 20 CFR 404.1514, 404.1624, 416.914, and 416.1024 of the Code of Federal Regulations.
10. The information provided on this form 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. Questions in form SSA-3827 relating to the nature of claimants’ impairments may be considered sensitive. However, SSA must collect this information to make an accurate disability determination.
12. An estimated 12,000 respondents take 30 minutes to complete form SSA-3827 each year. The total annual burden is therefore 6,000 hours. The total burden is reflected as burden hours, and no separate cost burden has been calculated.
13. There is no known cost burden to the respondents.
14. The annual cost to the Federal Government is approximately $255,840.00. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information (including compensation to those completing the form).
15. There is no change in the public reporting 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.
0960-0102 (SSA-3827)
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR FORM SSA 3826 |
| Author | 385919 |
| Last Modified By | 666429 |
| File Modified | 2007-12-06 |
| File Created | 2007-12-06 |