Disability Report - Adult

Forms and Documents

Document Name	Status
Form SSA-3368 Disability Report - Adult, (Paper Version) Form and Instruction	Unchanged
i3368 Screenshots - Revised to Include CAL.pdf Supplementary Document	2011-04-08
Justification for the Non-Substantive Changes - 0579.docx Justification for No Material/Nonsubstantive Change	2011-04-08

IC Document Collections

IC ID	Document Title	Status
9548	Disability Report - Adult, (Paper Version) Form and Instruction	Unchanged
179421	Disability Report - Adult, (i3368PRO) Other-i3368 PRO	Unchanged
179420	Disability Report - Adult, (Internet Version) Other-SSA-3368 (Internet)	Modified
179419	Disability Report - Adult (EDCS Version) Other-EDCS	Unchanged

ICR Details

OMB Control No: 0960-0579	ICR Reference No: 201104-0960-006
Status: Historical Active	Previous ICR Reference No: 200904-0960-012
Agency/Subagency: SSA	Agency Tracking No:
Title: Disability Report - Adult
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/23/2011
	Date Received in OIRA: 04/08/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2012	11/30/2012	11/30/2012
Responses	2,592,034	0	2,592,034
Time Burden (Hours)	2,757,163	0	2,757,163
Cost Burden (Dollars)	0	0	0

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Abstract: The Disability Report-Adult collects medical and other evidence which is used to determine whether an adult's impairment is disabling, and consequently, if that adult is entitled to Title II and/or Title XVI disability payments from the Social Security Administration. The information can be collected through the following ways: a paper form, in an SSA field office, an Internet version, and a new Internet version designed to be completed by professional advocacy groups. The respondents are adult disability applicants or their representatives.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 42 USC 405 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:
	74 FR 23916	05/21/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 37081	07/27/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Disability Report - Adult (EDCS Version)
Disability Report - Adult, (Internet Version)
Disability Report - Adult, (Paper Version)	SSA-3368	Disability Report - Adult -- Revised Version
Disability Report - Adult, (i3368PRO)

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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	2,592,034	2,592,034	0	0	0	0
Annual Time Burden (Hours)	2,757,163	2,757,163	0	0	0	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:

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Annual Cost to Federal Government: $34,708,811

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]? No

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: 04/08/2011

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