Function Report - Adult Third Party

Forms and Documents

Document Name	Status
Form SSA-3380 Individuals or Households Form and Instruction	Modified
Form SSA-3380 Private Sector Form and Instruction	Modified
Addendum 0635.doc Supplementary Document	2012-07-12
Supporting Statement 0635 (revised).doc Supporting Statement A	2012-09-25

IC Document Collections

IC ID	Document Title	Status
9663	Individuals or Households Form and Instruction	Modified
184838	Private Sector Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0635	ICR Reference No: 201206-0960-007
Status: Historical Active	Previous ICR Reference No: 200905-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Function Report - Adult Third Party
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: 10/31/2012
	Date Received in OIRA: 09/27/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2015	36 Months From Approved	11/30/2012
Responses	1,054,000	0	1,000,000
Time Burden (Hours)	1,071,566	0	1,016,666
Cost Burden (Dollars)	0	0	0

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Abstract: Individuals receiving or applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) provide SSA with medical evidence and other proof SSA requires to prove their disability. SSA, and Disability Determination Services (DDS) on our behalf, collect this information using Form SSA-3380-BK. We use the information to document how claimant's disabilities affect their ability to function, and to determine eligibility for SSI and SSDI claims. The respondents are third parties familiar with the functional limitations (or lack thereof) of claimants who apply for SSI and SSDI benefits.

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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:
	77 FR 40401	07/09/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 58903	09/24/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Individuals or Households	SSA-3380	Function Report -- Adult Third Party
Private Sector	SSA-3380	Function Report--Adult--Third Party

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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	1,054,000	1,000,000	0	0	54,000	0
Annual Time Burden (Hours)	1,071,566	1,016,666	0	0	54,900	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: There has been an increase in burden hours. This change stems from an increase in the number of respondents filing claims for disability benefits.

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Annual Cost to Federal Government: $14,608,440

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: 09/27/2012

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