supporting Statement for Form SSA‑3826
Medical Report (General)
20 CFR 404.1512-404.1515 and 416.912-.416.915
OMB No. 0960-0052
A. Justification
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 require an individual applying for disability benefits to provide medical evidence proving the existence and severity of an impairment.
Sections 20 CFR 404.1514 and 416.914 of the Code of Federal Regulations mandate that medical professionals completing this form receive a reasonable compensation for their time.
Using the state Disability Determination Services (DDS) as agents, SSA uses Form SSA- 3826-F4 to make accurate determinations in disability claims cases. SSA uses the information from this form to determine the claimant’s physical and mental status prior to making a disability determination, and to document the disability claim folder with the medical evidence. The form 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.
SSA uses the medical evidence from this form to determine if an individual’s impairment meets the severity and duration requirements for disability benefits. The respondents are members of the medical community, including individual physicians, hospital doctors, medical records librarians, and other medical sources.
OMB No. 0960-0555 provides the DDSs with the generic authority to use locally prepared letters to request medical evidence from medical sources on behalf of SSA. The use of this type of request has resulted in greatly decreased use of the printed SSA-3826. In addition, SSA has implemented the use of a computer-generated paper copy of the SSA-3826, which is available on demand by the DDSs or SSA components only. The respondent completes the form manually, and an SSA employee scans it electronically into SSA’s computer disability folder.
SSA did not create an electronic version of Form SSA-3826 under the agency’s Government Paperwork Elimination Act (GPEA) plan, because of the greatly reduced overall usage of the SSA-3826.
4. The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar data.
5. This collection does not significant affect small businesses or other small entities.
6. If we did not use Form SSA-3826, we would have to use more costly methods to verify, such as paying for a consultative exam, or we might have to deny disability benefits due to lack of evidence, which could result in us unfairly denying a claimant disability benefits. Because we only collect the information once, we cannot collect it less frequently.
There are no technical or legal obstacles to burden reduction.
7. There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
8. The 60-day advance Federal Register Notice published on June 22, 2010, at 75 FR 35512, and we received no public comments. SSA published the second Notice on September 03, 2010 at 75 FR 54211. If we receive comments in response to the 30-day Notice, we will forward them to OMB. We did not consult with the public on the revision/maintenance of this application.
We did not consult with the public in the revision of this form.
9. We provide payments to the respondents for their time completing Form SSA-3826 on behalf of SSA and are legally entitled to compensation.
10. SA 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.
11. Questions on form SSA-3826 relate to the nature of claimants’ impairments and are of sensitive nature. However, this information is necessary to make an accurate disability determination.
12. Approximately 150,000 respondents take 30 minutes each to complete form SSA-3826 each year. Accordingly, the burden is 75,000 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
13. This collection does not impose a known cost burden to the respondents.
14. The annual cost to the Federal Government is approximately $3,384,000. 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 are no changes to the public reporting burden.
16. SSA will not publish the results of the information collection.
17. 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.
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
SSA does not use statistical methods for this information collection.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR FORM SSA 3826 |
| Author | 385919 |
| Last Modified By | 889123 |
| File Modified | 2010-09-07 |
| File Created | 2010-06-25 |