Supporting Statement for Function Reports - Child
Forms SSA-3375, 3376, 3377, 3378, and 3379
20 CFR 416.912 and 416.924a(a)(2)
OMB No. 0960-0542
Introduction/Authoring Laws and Regulations
Section 1614(a)(3)(A) of the Social Security Act (the Act), as amended, provides that the Social Security Administration (SSA) considers children under age 18 disabled under title XVI of the Act if they have “…a medically determinable physical or mental impairment, which results in marked and severe functional limitations….” Sections 1614 (a)(3)(H)(i), 223(d)(5)(A), and 1631(e)(1)(A) of the Act and 20 CFR 416.912 of the Code of Federal Regulations, grant SSA the authority to establish requirements for the collection of information to help determine a child’s eligibility under title XVI.
To assess a child claimant’s functional limitations, the agency must collect information from those in a position to know of the child’s daily functioning, including the child’s parent(s) or other primary caregiver(s) (hereinafter referred to just as “parent”). This is discussed in 20 CFR 416.924a(a)(2).
Description of Collection
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, we only use one version for each particular child. While we do not require respondents to complete the form, it is beneficial for them to do so.
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 children’s ability to function and of their impairment-related limitations. We only collect this information once per child applying for disability. 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.
When we complete these forms in an interview setting in the field office, the interviewer helps the parents complete the form. In some instances, however, parents fill out the forms at home. The respondents are parents and/or guardians of child applicants for Supplemental Security Income (SSI) payments.
Use of Information Technology To Collect the Information
In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an electronic version of these forms. When we complete these forms in an interview setting in the field office, or via telephone, the SSA field office employees enter the information through the Electronic Disability Control System (EDCS). In some instances, however, parents fill out the forms at home on paper. Based on our data, we estimate that approximately 90% of respondents use EDCS rather than submitting the paper version.
Why We Cannot Use Duplicate Information
We coordinated the development of these forms with the development and revision of other forms used in childhood disability cases, e.g., Forms SSA-3820 and SSA-3881, to avoid duplication. SSA does not have any similar information about a child’s daily functioning that we could use in place of information from the child’s parent – no source has more information about the child’s daily functioning. There are, of course, other sources of information about a child’s functioning including schoolteachers, in particular, and we collect information from all other such sources. However, the regulations require us to form a complete picture of a child’s ability to function, and this would be impossible without consideration of the child’s functioning in the home setting.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequence of Not Collecting Information or Collecting It Less Frequently
In a given claim, the DDSs collect the information once as part of the initial claims process. We may collect updated information if we conduct a continuing disability review regarding a child who is already receiving benefits. If the DDSs did not collect this information on our behalf, it would significantly compromise SSA’s ability to make accurate and supportable disability determinations in childhood disability cases. There are no technical or legal obstacles to burden reduction.
Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on May 13, 2010, at 75 FR 27036, and SSA received no public comments. The 30-day Notice published on August 2, 2010, at 75 FR 45190. If we receive any comments in response to the 30-day Notice, we will forward them to OMB. SSA did not consult members of the public in the development or maintenance of this form.
Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
Assurances of Confidentiality
SSA protects and holds confidential the information it collects 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.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
When initially applying for SSI benefits on behalf of a child, we ask each respondent (Individuals/Households only) to provide one response to the Function Report form that is appropriate to the child’s age. We may need an additional response if we conduct a continuing disability review (CDR) of the child’s case. Based on case counts in the 2009 SSI Report to Congress, approximately 500,000 respondents complete Forms SSA-3375, 3376, 3377, 3378 and 3379 annually in initial and continuing disability cases. It takes approximately 20 minutes to fill out the appropriate form for a particular child’s age, for a total annual burden of 166,667 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
Annual Cost to the Respondents
This collection does not impose a known cost burden to the respondents.
Annual Cost to Federal Government
Estimated annual cost to the Federal Government is approximately $7,155,500. This estimate is a projection of the costs for printing and distributing the paper forms and for collecting the information on all five Function Report forms, plus the annual burden hours of completion of the MSSICS screens at the field offices ($44.88/hour X 1/3 hour X 450,000 responses = $6,732,000).
Program Changes or Adjustments to the Information Collection Request
There was a decrease in the number of respondents as per the 2009 SSI Report to Congress. SSA did not take any actions to cause this decrease.
Plan for Publication of Results of Information Collection
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
Exemptions to Certification Statement
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
SSA does not use statistical methods for this information collection.
| File Type | application/msword |
| File Title | Supporting Statement for Report of Function – Child |
| Author | 100150 |
| Last Modified By | 889123 |
| File Modified | 2010-08-05 |
| File Created | 2010-08-04 |