Supporting Statement 0577 (revised)

Supporting Statement for the

Disability Report-Child (SSA-3820-BK; i3820)

20 CFR 416.912

OMB No. 0960-0577

1. Justification

1. Introduction/Authorizing Laws and Regulations

Sections 205(a) and 1631(d)(1) of the Social Security Act (the Act), provides the Commissioner of the Social Security Administration (SSA) full power and authority to make rules and regulations, establish procedures, and to adopt reasonable and proper rules for the nature and extent of the evidence needed, as well as the methods of taking and furnishing the same, to evaluate the alleged disability. Sections 223 (d)(5)(A) and 1631(e)(1) of the Act require that claimants for SSA benefits furnish such medical and other evidence of disability as the Commissioner may require to prove that they are disabled.

20 CFR 416.912 of the Code of Federal Regulations, specifically states, among other things, that individuals will furnish medical evidence and, if asked, evidence of age, education and training, work experience, efforts to work, and any other evidence showing how their impairment(s) affects the ability to work, or in the case of a child, the ability to function. SSA uses Form SSA-3820-BK, Disability Report-Child, to help collect this information.

2. Description of Collection

SSA uses Form SSA-3820 to collect various types of information about a child’s condition from treatment sources or other medical sources of evidence. State Disability Determination Services evaluators use the information Form SSA-3820 provides to develop medical and school evidence, and to assess the alleged disability. The information, together with medical evidence, forms the evidentiary basis upon which SSA makes its initial disability evaluation. The respondents are claimants seeking SSI childhood disability payments.

Claimants can complete and print Form SSA-3820-BK and mail to SSA, or take the notification page to their local Social Security field office (FO). The notification page serves as a back-up alert to the FOs that an applicant transmitted an internet disability report. The Electronic Disability Collect System (EDCS) is an internal collection process. When claimants do not complete an i3820, field office (FO) employees use EDCS to key information provided by claimants onto EDCS screens to establish a database for the DDS adjudicators.

3. Use of Information Technology to Collect the Information

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an Internet version of form SSA-3820-BK. Based on our data, we estimate approximately 99% of respondents under this OMB number use the electronic version.

4. Why We Cannot Use Duplicate Information

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. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently

If we did not use form SSA-3820-BK, we would not be able to determine whether the claimant qualifies for disability. Because we only collect the information once, we cannot collect it less frequently.

There are no technical or legal obstacles to burden reduction.

7. 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.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on June 28, 2013, at

78 FR 39054, and we received no public comments. The 30-day FRN published on September 12, 2013 at 78 FR 56265. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.

9. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

10. 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 0MB Circular No. A-130.

11. Justification for Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
SSA-3820	500	1	90	750
EDC	1,000	1	120	2,000
I3820	540,000	1	60	540,000
Totals	541,500			542,750

The total burden for this ICR is 542,750 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents

This collection does not impose a known cost burden on the respondents.

14. Annual Cost to Federal Government

The annual cost to the Federal government is approximately $163,750. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request

There has been an increase in burden hours. The increase stems from an increase in the users completing the internet version of Form SSA-3820 (i3820).

16. Plan for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

For the paper Form SSA-3820-BK, we will not publish 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.

For the Internet version (i3820) of form SSA-3820-BK, SSA is not requesting an exception to the requirement to display the OMB approval expiration date.

18. 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).

2. Collection of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.