Disability Report - Child

Forms and Documents

Document Name	Status
Form SSA-3820-BK Disability Report - Child (Paper) Form and Instruction	Modified
Justification for Non-substtantive changes 0960-0577.doc Justification for No Material/Nonsubstantive Change	2015-05-14

IC Document Collections

IC ID	Document Title	Status
9538	Disability Report - Child (Paper) Form and Instruction	Modified
179519	Disability Report - Child (Internet) Other-Disability Report - Child (Internet)	Unchanged
179518	Disability Report - Child (EDCS) Other-EDCS	Unchanged

ICR Details

OMB Control No: 0960-0577	ICR Reference No: 201505-0960-013
Status: Historical Active	Previous ICR Reference No: 201304-0960-010
Agency/Subagency: SSA	Agency Tracking No:
Title: Disability Report - Child
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: 05/15/2015
	Date Received in OIRA: 05/14/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2016	11/30/2016	11/30/2016
Responses	541,500	0	541,500
Time Burden (Hours)	542,750	0	542,750
Cost Burden (Dollars)	0	0	0

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Abstract: When claimants file a claim for childhood disability benefits under the SSI program, they must furnish medical and other evidence to prove they are disabled. Form SSA–3820 collects various types of information about a child’s condition from treating sources and/or other medical sources of evidence. The DDS evaluators use the information 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. Non-substantive change request: We are adding a fillable PDF version of the collection instrument Form SSA-4162, Child Care Dropout Questionnaire.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 42 USC 423 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:
	78 FR 39054	06/28/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 56265	09/12/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Disability Report - Child (Paper)	SSA-3820-BK, SSA-3820-BK	Disability Report - Child ,   Disability Report - Child
Disability Report - Child (Internet)
Disability Report - Child (EDCS)

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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	541,500	541,500	0	0	0	0
Annual Time Burden (Hours)	542,750	542,750	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: $163,750

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: 05/14/2015

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