Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)

Forms and Documents

Document Name	Status
Form SSA-3376 Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2) Form	Modified
Supporting Statement - 0542.doc Supporting Statement A	2010-08-05
Addendum - 0542.doc Supplementary Document	2010-08-04

IC Document Collections

IC ID	Document Title	Status
9455	Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2) Form	Modified

ICR Details

OMB Control No: 0960-0542	ICR Reference No: 201004-0960-001
Status: Historical Active	Previous ICR Reference No: 200706-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/15/2010
	Date Received in OIRA: 08/05/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2013	36 Months From Approved	11/30/2010
Responses	500,000	0	550,000
Time Burden (Hours)	166,667	0	183,333
Cost Burden (Dollars)	0	0	0

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Abstract: 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, respondents use only one version for each particular child. The adjudicative team (disability examiners and medical/psychological consultants) of state disability determination services (DDSs) collects the information 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. The respondents are parents and/or guardians of child applicants for Supplemental Security Income (SSI) payments.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 1382c Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 27036	05/13/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 45190	08/02/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)	SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379	Function Report-Child Age 1 to 3rd Birthday ,   Function Report-Child Birth to 1st Birthday ,   Function Report-Child Age 3 to 6th Birthday ,   Function Report - Child Age 6 to 12th Birthday ,   Function Report - Child Age 12 to 18th Birthday

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	500,000	550,000	0	0	-50,000	0
Annual Time Burden (Hours)	166,667	183,333	0	0	-16,666	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: We based the change in the number of respondents on data in the 2009 SSI Report to Congress.

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Annual Cost to Federal Government: $7,155,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/05/2010

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