Addendum to the Supporting Statement for 0960-0072

ADDENDUM TO SUPPORTING STATEMENT FOR

FORM SSA-454-BK,

CONTINUING DISABILITY REVIEW REPORT

(OMB No. 0960-0072)

Revision to the Collection Instrument

We have revised this form to reflect the format and language, when appropriate, currently found in Form SSA-3368-BK (Disability Report – Adult) (OMB No. 0960-0579) and Form SSA-3441-BK (Disability Report – Appeal) (OMB No. 0960-0144).

We added a block to capture the email address of the disabled person’s friend or relative listed in Section 1, Item E.

We changed the wording for the column title for the date of a test(s) in Section 5 to make it grammatically correct.

We expanded the wording of the question in Section 8 of the paper form to make the respondent more aware of the specific kinds of plans or programs we are asking about.

We restructured the information at the bottom of Section 10 to eliminate duplicate information collection if the respondent is the person identified in Section 1, Item E. The duplicate information eliminated the respondent’s address. If the respondent is the person identified in Section 1, Item G., we will have already collected his or her address in Item E. We need to collect address information here only if the respondent is neither the disabled person nor the person identified in Section 1, Item E. This information enables us to contact the respondent by mail if we are unsuccessful in doing so by telephone (or email). We want to collect the respondent’s telephone number to permit a more expeditious contact with him or her if we need to clarify information on the form or obtain missing information. We also revised the wording in the “Name” box so that the disabled person doesn’t have to enter his or her name again. We did this because we agreed to do it as a result of a passback on the SSA-3368 (0960-0579), which OMB approved on 2/1/08.

Summary of Implementation Plan:

Upon approval by OMB, we will revise the form on the eForm website only. We will reprint the preprinted paper form the next time it comes due for reprinting.

Disposition Instructions for Previous Version:

We will continue to use existing stock until it is exhausted.

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