As part of SSA’s disability
determination process, we use Forms SSA-3375-BK through SSA-3379-BK
to request information from a child’s parent or guardian for
children applying for Supplemental Security Income (SSI). The five
different versions of the form contain questions about the child’s
day-to-day functioning appropriate to a particular age group; thus,
respondents use only one version of the form for each child. The
adjudicative team (disability examiners and medical or
psychological consultants) of State disability determination
services offices collect the information on the appropriate version
of this form (in conjunction with medical and other evidence) to
form a complete picture of the children’s ability to function and
their impairment-related limitations. The adjudicative team uses
the completed profile to determine: (1) if each child’s
impairment(s) results in marked and severe functional limitations;
and (2) whether each child is disabled. The respondents are parents
and guardians of child applicants for SSI.
US Code:
42
USC 423 Name of Law: Social Security Act
US Code: 42
USC 1382c Name of Law: Social Security Act
US Code: 42
USC 1383 Name of Law: Social Security Act
The decrease in the number of
respondents for this collection is due to a decrease in use based
on our current case data in the 2015 Annual Report of the
Supplemental Security Income Program. SSA did not initiate any
program changes that would cause a decrease in respondents.
$4,358,700
No
No
No
No
No
Uncollected
Faye Lipsky 410 965-8783
faye.lipsky@ssa.gov
No
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:
(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;
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.
Form SSA-3375 Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)
Addendum - 0542.docx
Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)