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 of the Code of Federal Regulations 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 impairment affects their ability to work. Form SSA-3380-BK collects this evidentiary information.
Form SSA-3380-BK collects the types of evidence cited above. 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, completes this form. The State Disability Determination Services (DDS) evaluators use the information on the SSA-3380-BK 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 is not currently available in an electronic format because SSA has had to devote its limited resources to other, more urgent electronic projects that our claimants use more frequently. As noted earlier, the State DDSs use this form. The DDSs mail this form to the respondent. DDSs do not have the systems access that will accept Internet data. However, SSA plans to reevaluate this form for electronic conversion within the next few years.
4. The nature of the information 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 DDSs did not collect this information, they 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 DDSs only collect the information once for an initial application or for when the claimant files an appeal, they cannot collect the information less frequently. There are no technical or legal obstacles that prevent burden reduction.
7. There are no special circumstances that would cause SSA to conduct this information collection in a manner that is not consistent with 5 CFR 1320.5.
8. The 60-day advance Federal Register Notice published on May 21, 2009, at 74 FR 23916, and SSA has received no public comments. The second Notice published on July 27, 2009 at 74 FR 37081. 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 61 minutes to complete form SSA-3380-BK each year. Therefore, the total annual burden is 1,016,666 hours. The total burden reflects as burden hours, and SSA has calculated no separate cost burden. 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 is a change in the public reporting burden. On our prior Form-SSA-3380, we erroneously noted that we estimated that it would take 30 minutes to read the instructions, gather the facts and answer the questions. This was a typographical error. We intended to indicate that it would take 60 minutes to complete the form. We moved two questions from the former Form SSA-3368 (Disability Report) to the Form SSA-3380. This change resulted in a one-minute increase in the burden per response.
16. SSA will not publish the results of the information collection.
17. OMB has granted SSA an exemption from the requirement to print the expiration date for OMB approval 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). OMB granted this exemption so that SSA would not need to take otherwise useable editions of forms out of circulation because the expiration date had been reached. In addition, SSA avoids Government waste because we will not need to destroy or reprint stocks of forms.
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.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR FORM SSA-3380-BK |
| Author | 654350 |
| Last Modified By | 177717 |
| File Modified | 2009-07-28 |
| File Created | 2009-07-28 |