Supporting Statements for RIN 0960-AH86

Supporting Statement for Form SSA-454-BK
Continuing Disability Review Report
20 CFR 404.1589 & 416.989
OMB No. 0960-0072
A.

Justification
1.

Introduction/Authoring Laws and Regulations
Sections 205(a) and 1631(e)(1)(A) of the Social Security Act (Act) provide the
Commissioner of the Social Security Administration (SSA) with full power and
authority to make rules and regulations; establish procedures; and adopt
reasonable and proper procedures governing the nature and extent of the evidence
(as well as the methods of taking and furnishing the same) to determine whether
an individual continues to be disabled. Sections 223(d)(5)(A) and
1614(a)(3)(H)(i) of the Act, as amended, provide that claimants furnish such
medical and other evidence required by the Commissioner to prove they continue
to be disabled. Sections 221(i), 1614(a)(3)(H)(ii)(I) and 1633 (c)(1) of the Act
require us to periodically review the cases of individuals who receive benefits
under Title II or Title XVI of the Act, based on disability, to determine if
disability continues. As provided in 20 CFR 404.1589 and 20 CFR 416.989 of
the Code of Federal Regulations, we may conduct a review to determine whether
benefit entitlement or eligibility continues for individuals receiving disability
benefits.
We are including the Information Collection Requests (ICR) for 0960-0072
(SSA-454; i454); 0960-0144 (SSA-3441; i3441); 0960-0579 (SSA-3368; i3368);
0960-0632 (SSA-3380-BK); and 0960-0681 (SSA-3373-BK), under one new
OMB Control Number, 0960-0XXX for the purposes of obtaining OMB approval
for the revisions we are making to these forms as part of the Rulemaking process
for the Removing the Education Category - Inability to Communicate in English from the Disability Determination Process, RIN 0960-AH86. For technical
purposes, we need to keep the regulatory-related changes to these forms on a
separate track through the publication of the Final Rule stage, as we need to
continue to use these forms, and renew their current OMB approvals, while
simultaneously obtaining approval for the changes due to the revised rules under
RIN 0960-AH86. To ensure we maintain OMB’s approval for the current
versions of the forms, we will maintain this separate OMB number for duration of
the NPRM and Final Rule changes to RIN 0960-AH86. Once we publish the
Final Rule, we will update these forms under their separate OMB Control
Numbers and discontinue the new OMB approval, 0960-0XXX, as we will no
longer require it.
We are making these changes to our Regulations because the education category
“inability to communicate in English” is no longer a reliable indicator of an
individual’s educational attainment or the vocational impact of an individual’s
education. We published the Notice of Proposed Rulemaking, RIN 0960-AH86,

on February 1, 2019, at 84 FR 1006.
2.

Description of Collection
SSA uses Form SSA-454-BK (Continuing Disability Review Report) to complete
a mandatory review for the continue disability review (CDR). SSA considers
adults eligible for payment if they continue to be unable to do substantial gainful
activity because of their impairments, and we consider Title XVI children eligible
for payment if they have marked and severe functional limitations because of their
impairments. SSA also uses Form SSA-454-BK to obtain information on sources
of medical treatment; participation in vocational rehabilitation programs (if any);
attempts to work (if any); and to update information if individuals believe their
conditions improved. When a disabled individual requires a CDR, either a claims
representative (CR) mails Form SSA-454-BK, the respondent completes the form
and sends it back to SSA, or the CR interviews the respondent and enters the
information into the Electronic Disability Collection System (EDCS). EDCS
electronically stores the information of the paper version of the Form
SSA-454-BK. The respondents are Title II or Title XVI disability recipients or
their representatives.

3.

Use of Information Technology to Collect the Information
In accordance with the agency’s Government Paperwork Elimination Act plan,
SSA created an Intranet, EDCS, version of Form SSA-454-BK. Based on our
data, we estimate approximately 50% of respondents under this OMB number use
the electronic version as part of a personal interview with a CR.

4.

Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect 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-454-BK, we would be unable to make a timely
determination regarding if and when recipients should stop receiving disability
payments (either because adults are able to work, or Title XVI children no longer
have marked and severe functional limitations). Because we collect the
information on an as needed basis, 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
SSA published a notice of proposed rulemaking (NPRM) in the Federal Register
on February 1, 2019, at 84 FR 1006. If we receive any comments in response to
the NPRM, we will forward them to OMB. When we publish the Final Rule, we
will re-submit this ICR for formal approval of the information collection
requirements described within.

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 OMB 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

SSA-454- BK
(Paper version)
EDCS
Totals

Number of
Frequency
Respondents of
Response

270,500
270,500
541,000

1
1

Average
Burden
per
Response
(minutes)

Estimated
Total Annual
Burden
(hours)

60
60

270,500
270,500
541,000

The total burden for this ICR is 541,000 hours. We based these figures on current
management information data. We did not calculate a separate cost burden.
13.

Annual Cost to the Respondents (Other)
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 $14,465,629. This
estimate accounts for costs from the following areas: (1) designing, printing, and
distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS
staff) information collection and processing time; and (3) systems development,
updating, and maintenance costs.

15.

Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.

16.

Plans 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-454-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 Intranet, EDCS, version of Form SSA-454-BK, SSA is not requesting an
exception to the requirement to display the OMB approval expiration date.

18.

B.

Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements in 5 CFR
1320.9 and related provisions in 5 CFR 1320.8(b)(3).

Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.

Supporting Statement for Form SSA-3441
Disability Report-Appeal
20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 422.140, 404.1713, 416.1513,
404.1740(b)(4), 416.1540(b)(4), and 20 CFR 405, Subpart C
OMB No. 0960-0144
A.

Justification
1.

Introduction/Authoring Laws and Regulations
Sections 205(a), 223(d), and 1631(e) of the Social Security Act (Act), as well as
20 CFR 404.1512 and 416.912 of the Code of Federal Regulations (Code) require
individuals filing for Social Security or Supplemental Security Income (SSI)
benefits based on disability to provide evidence showing how their impairment(s)
affect their ability to work or function. 20 CFR 404.916(c) and 416.1416(c) state
that SSA will include any new evidence applicants submit in connection with
their request for reconsideration in this review. Section 205(b) of the Act, as well
as 20 CFR 405, Subpart C, and 20 CFR 422.140 of the Code, requires the Social
Security Administration (SSA) to provide a reconsideration of an initial denial at
the State Disability Determination Services (DDS) level, and an evidentiary
hearing at the reconsideration appeal level, for individuals who appeal an
unfavorable disability determination. SSA denies the claim when we find the
physical or mental impairment for which such benefits are payable to have
ceased; not to have existed; or not to be disabling. 20 CFR 404.1713 and
416.1513, which include mandatory use of electronic services, as well as 20 CFR
404.1740(b)(4) and 416.1540(b)(4) require a representative requesting direct fee
payment to conduct business with us electronically at the times and in the manner
we prescribe.
We are including the Information Collection Requests (ICR) for 0960-0072
(SSA-454; i454); 0960-0144 (SSA-3441; i3441); 0960-0579 (SSA-3368; i3368);
0960-0632 (SSA-3380-BK); and 0960-0681 (SSA-3373-BK), under one new
OMB Control Number, 0960-0XXX for the purposes of obtaining OMB approval
for the revisions we are making to these forms as part of the Rulemaking process
for the Removing the Education Category - Inability to Communicate in English from the Disability Determination Process, RIN 0960-AH86. For technical
purposes, we need to keep the regulatory-related changes to these forms on a
separate track through the publication of the Final Rule stage, as we need to
continue to use these forms, and renew their current OMB approvals, while
simultaneously obtaining approval for the changes due to the revised rules under
RIN 0960-AH86. To ensure we maintain OMB’s approval for the current
versions of the forms, we will maintain this separate OMB number for duration of
the NPRM and Final Rule changes to RIN 0960-AH86. Once we publish the
Final Rule, we will update these forms under their separate OMB Control
Numbers and discontinue the new OMB approval, 0960-0XXX, as we will no
longer require it.

We are making these changes to our Regulations because the education category
“inability to communicate in English” is no longer a reliable indicator of an
individual’s educational attainment or the vocational impact of an individual’s
education. We published the Notice of Proposed Rulemaking, RIN 0960-AH86,
on February 1, 2019, at 84 FR 1006.
2.

Description of Collection
SSA requires disability applicants who wish to appeal an unfavorable disability
determination to complete Form SSA-3441. This form allows claimants to
disclose any changes to their disability or resources that might influence SSA’s
unfavorable determination. SSA may use the information to: (1) reconsider and
review an initial disability determination; (2) review a continuing disability; and
(3) evaluate a request for a hearing. The information SSA requests on the
SSA-3441 facilitates collecting medical and nonmedical information to support
the applicant’s request for reconsideration; request for benefits cessation appeal;
and request for a hearing before an administrative law judge (ALJ). The
information we collect also assists the State DDSs and administrative law judges
(ALJs) in: (1) preparing for the appeals and hearings; and (2) issuing a
determination or decision on an individual’s entitlement (initial or continuing) to
disability benefits. We collect the information via the SSA-3441-BK (paper
form); Electronic Disability Collect System (EDCS); and i3441 Internet screens.
The respondents complete the SSA-3441 by themselves either on paper or online.
If the respondent completes the paper form, they mail it ahead of time or bring it
into the field office (FO) when they have an appointment for an interview, and a
claims representative keys the information into EDCS. If the respondent
completes the i3441, the Field Office uses the information to file the claim.
Respondents are individuals who appeal denial, reduction, or cessation of Social
Security disability income and Supplemental Security Income (SSI) payments;
who are requesting a hearing before an ALJ; or their representatives.

3.

Use of Information Technology to Collect the Information
In accordance with the agency’s Government Paperwork Elimination Act plan,
SSA created two electronic versions of form SSA-3441. SSA designed the
electronic methods to collect the same information as the paper form, but they
may be formatted differently and may include certain enhancements (e.g.,
instructions for claims representatives, help screens, dynamic pathing, etc.) to
guide the interviewer or applicant through the appeal process. Based on our data,
we estimate approximately 99.7% of the total responses are either collected
through EDCS screens, or via the Internet version of the form (i3441).

4.

Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect 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-3441, the public would have no way to apply for
reconsideration, benefits cessation appeal, or for a hearing before an ALJ. This
would violate Sections 221(c) and (d) of the Act. Because we 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
SSA published a notice of proposed rulemaking (NPRM) in the Federal Register
on February 1, 2019, at 84 FR 1006. If we receive any comments in response to
the NPRM, we will forward them to OMB. When we publish the Final Rule, we
will re-submit this ICR for formal approval of the information collection
requirements described within.

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 OMB 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
Number of
Frequency Average
Completion
Respondents of Response Burden
Per
Response
(minutes)
SSA-3441-BK
2,396
1
45
(Paper Form)
Electronic
476,771
1
45
Disability Collect
System (EDCS)
i3441
1,046,938
1
28
(Internet Form)
Totals
1,526,105

Estimated
Annual
Burden
(hours)
1,797
357,578
488,571
847,946

The total burden for this ICR is 847,946 hours. We based these figures on current
management information data. We did not calculate a separate cost burden.
13.

Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden to the respondents.

14.

Annual Cost to Federal Government
The annual cost to the Federal Government is approximately $53,870. This
estimate accounts for costs from the following areas: (1) designing, printing, and
distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS
staff) information collection and processing time; and (3) systems development,
updating, and maintenance costs.

15.

Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.

16.

Plans 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-3441-BK, SSA 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 the OMB approval date. Since SSA
does not periodically (e.g., on an annual basis), revise and reprint its public-use
forms, OMB granted this exemption so SSA would not have to destroy stocks of
otherwise useable forms with expired OMB approval dates, thereby avoiding
Government waste.
For the electronic versions of the form (EDCS-3441 and i3441), SSA is not
requesting an exception to the requirement to display the OMB approval
expiration date.

18.

B.

Exceptions 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).

Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.

Supporting Statement for the SSA-3368
Disability Report-Adult
20 CFR 404.1512 and 416.912
OMB No. 0960-0579
A.

Justification
1.

Introduction/Authoring Laws and Regulations
Adult applicants for Social Security Administration (SSA) disability benefits must
provide medical, job history, and any other evidence required by SSA’s
Commissioner to prove that his or her impairment(s) is disabling. Since SSA
needs a vehicle to collect this evidence, we use the paper Form SSA-3368 and its
electronic versions, Electronic Disability Collect System (EDCS) 3368 and the
Internet i3368, for this purpose. Sections 223(d)(5)(A) and 1631(e)(1) of the
Social Security Act (Act) a provide that an individual must furnish medical and
other evidence to prove he or she is disabled. Implementing the regulations in
sections 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations state
an individual must inform us about or submit all evidence known or relates to
whether or not he or she is blind or disabled, and if asked, inform us about
medical sources, age, education and training, work experience, daily activities
efforts to work, and any other factors showing how impairment(s) affects his or
her ability to work. Sections 205(a) and 1631(d)(1) of the Act give the
Commissioner the authority to establish regulations and procedures governing the
type of evidence needed to evaluate an alleged disability and methods of
collecting this evidence.
We are including the Information Collection Requests (ICR) for 0960-0072
(SSA-454; i454); 0960-0144 (SSA-3441; i3441); 0960-0579 (SSA-3368; i3368);
0960-0632 (SSA-3380-BK); and 0960-0681 (SSA-3373-BK), under one new
OMB Control Number, 0960-0XXX for the purposes of obtaining OMB approval
for the revisions we are making to these forms as part of the Rulemaking process
for the Removing the Education Category - Inability to Communicate in English from the Disability Determination Process, RIN 0960-AH86. For technical
purposes, we need to keep the regulatory-related changes to these forms on a
separate track through the publication of the Final Rule stage, as we need to
continue to use these forms, and renew their current OMB approvals, while
simultaneously obtaining approval for the changes due to the revised rules under
RIN 0960-AH86. To ensure we maintain OMB’s approval for the current
versions of the forms, we will maintain this separate OMB number for duration of
the NPRM and Final Rule changes to RIN 0960-AH86. Once we publish the
Final Rule, we will update these forms under their separate OMB Control
Numbers and discontinue the new OMB approval, 0960-0XXX, as we will no
longer require it.
We are making these changes to our Regulations because the education category
“inability to communicate in English” is no longer a reliable indicator of an

individual’s educational attainment or the vocational impact of an individual’s
education. We published the Notice of Proposed Rulemaking, RIN 0960-AH86,
on February 1, 2019, at 84 FR 1006.
2.

Description of Collection
State Disability Determination Services (DDS) use Form SSA-3368 and its
electronic versions to determine if an adult disability applicant’s impairment(s) is
severe and, if so, how the impairment(s) affects the applicant’s ability to work.
This determination dictates whether or not the DDS and SSA will find the
applicant disabled and entitled to SSI payments. The respondents are applicants
for Title II disability benefits or Title XVI SSI payments.

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-3368. Based on our data, we
estimate approximately 97 percent of respondents under this OMB number use
the electronic versions. SSA designed the electronic modalities to collect the
same information as the paper form, however it is formatted differently to include
certain enhancements (e.g., instructions and help screens) to guide the interviewer
or applicant through the application process.


Electronic Disability Collect System (EDCS) SSA-3368:
Applicants may call or go into the SSA Field Office to provide the
information the collection requires. In these cases, a claims representative
interviews the applicant and enters his or her answers directly into the
EDCS SSA-3368. Approximately 86 percent of respondents use this
option.



Internet 3368 (i3368):
The i3368 is a fully electronic version of the paper form. Adult disability
applicants or their representatives may access, complete, and submit the
SSA-3368 electronically through this internet-based application. SSA
designed the i3368 to walk first-time users through this information
collection. It contains numerous help screens and explanations about why
we ask certain questions on the form. Approximately 11 percent of
respondents use this option.

We also provide applicants with “fillable” and printable PDF version of the form
on SSA’s website.
4.

Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it
precludes duplication. SSA does not use another collection instrument to obtain
similar data.

5.

Minimizing Burden on Small Respondents
This collection does not significantly 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-3368, the public have no way to apply for disability
benefits. We would deprive individuals of the right to present evidence pertaining
to their claim. Because we collect the information on an as needed basis, 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
SSA published a notice of proposed rulemaking (NPRM) in the Federal Register
on February 1, 2019, at 84 FR 1006. If we receive any comments in response to
the NPRM, we will forward them to OMB. When we publish the Final Rule, we
will re-submit this ICR for formal approval of the information collection
requirements described within.

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 OMB 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
SSA-3368
(Paper form)
Electronic
Disability
Collection
System (EDCS)
i3368 (Internet)

Number of
Frequency Average
Respondents of
Burden Per
Response Response
(minutes)

Estimated
Annual
Burden
(hours)

7,571

1

90

11,357

2,484,231
1,060,360

1
1

90
90

3,726,347
1,590,540

Totals

3,552,162

5,328,244

The total burden for this information collection request is 5,328,244 hours. We
based these figure on current management data. This figure represents burden
hours, and we did not calculate a separate cost burden.
13.

Annual Cost to the Respondents (Other)
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 $35,958,328. This
estimate accounts for costs from the following areas: (1) designing, printing, and
distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS
staff) information collection and processing time; and (3) systems development,
updating, and maintenance costs.

15.

Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.

16.

Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.

17.

Displaying the OMB Approval Expiration Date
For our paper Form SSA-3368, 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 our Internet i3368, SSA is not requesting an exception to the requirement to
display the OMB approval expiration date.

18.

B.

Exceptions 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).

Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.

Supporting Statement for Form SSA-3380-BK
Function Report – Adult Third Party
20 CFR 404.1512, 404.1564, 416.912, and 416.964
OMB No. 0960-0635
A.

Justification
1.

Introduction/Authoring Laws and Regulations
Sections 205(a), 223(d)(5)(A), 1631(d)(1), and 1631(e)(1) of the Social Security
Act (the Act) require claimants for Social Security disability benefits to provide
medical and other evidence of their disability, with evidence requirements to be
established by the Commissioner of Social Security. These sections of the Act
also grant the Social Security Administration (SSA) the authority to establish
procedures for collecting and verifying this evidence. 20 CFR 404.1512 and
416.912 of the Code of Federal Regulations require claimants to provide the
following information: evidence of age; education and training; work experience;
daily activities; efforts to work; and any other evidence demonstrating how their
impairment affects their ability to work.
We are including the Information Collection Requests (ICR) for 0960-0072
(SSA-454; i454); 0960-0144 (SSA-3441; i3441); 0960-0579 (SSA-3368; i3368);
0960-0632 (SSA-3380-BK); and 0960-0681 (SSA-3373-BK), under one new
OMB Control Number, 0960-0XXX for the purposes of obtaining OMB approval
for the revisions we are making to these forms as part of the Rulemaking process
for the Removing the Education Category - Inability to Communicate in English from the Disability Determination Process, RIN 0960-AH86. For technical
purposes, we need to keep the regulatory-related changes to these forms on a
separate track through the publication of the Final Rule stage, as we need to
continue to use these forms, and renew their current OMB approvals, while
simultaneously obtaining approval for the changes due to the revised rules under
RIN 0960-AH86. To ensure we maintain OMB’s approval for the current
versions of the forms, we will maintain this separate OMB number for duration of
the NPRM and Final Rule changes to RIN 0960-AH86. Once we publish the
Final Rule, we will update these forms under their separate OMB Control
Numbers and discontinue the new OMB approval, 0960-0XXX, as we will no
longer require it.
We are making these changes to our Regulations because the education category
“inability to communicate in English” is no longer a reliable indicator of an
individual’s educational attainment or the vocational impact of an individual’s
education. We published the Notice of Proposed Rulemaking, RIN 0960-AH86,
on February 1, 2019, at 84 FR 1006.

2.

Description of Collection
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. Respondents
include family members, neighbors, friends, etc., and past employers.
3.

Use of Information Technology to Collect the Information
Form SSA-3380 is available as a fillable PDF on SSA’s website, which the
respondent completes, prints, and mails to SSA. The DDS also mails the form to
the respondent to complete and mail back. SSA has not, yet, created an electronic
version of Form SSA-3380 under the agency’s Government Paperwork
Elimination Act (GPEA) plan due to competing priorities.

4.

Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect 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 collect this information, it would be impossible to determine
whether claimants are disabled, or beneficiaries are still disabled, and SSA would
not be able to discharge its mandate to pay benefits to those who are disabled.
Since the form is completed only once for an initial application, and on an
occasional basis if a beneficiary is selected for a continuing disability review or
appeals our decision, the information cannot be collected 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
SSA published a notice of proposed rulemaking (NPRM) in the Federal Register
on February 1, 2019, at 84 FR 1006. If we receive any comments in response to
the NPRM, we will forward them to OMB. When we publish the Final Rule, we
will re-submit this ICR for formal approval of the information collection
requirements described within.

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 OMB Circular No. A-130.

11.

Justification for Sensitive Questions
This information collection does not contain any questions of a sensitive nature.

12.

Estimates of Public Reporting Burden
Modality of
Completion

SSA-3380-BK

Number of
Frequency Average
Respondents of
Burden Per
Response Response
(minutes)
709,700
1
61

Estimated
Total Annual
Burden
(hours)
721,528

The total burden for this ICR is 721,528. We based these figures on current
management information data. We did not calculate a separate cost burden.
13.

Annual Cost to the Respondents (Other)
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 $1,508,783. This
estimate accounts for costs from the following areas: (1) designing, printing, and
distributing the form; and (2) SSA employee (e.g., field office, 800 number, DDS
staff) information collection and processing time.

15.

Program Changes or Adjustments to the Information Collection Request
When we last cleared this IC in 2015, the burden was 793,000 hours. However,
we are currently reporting a burden of 721,528 hours. This change stems a
decrease in the number of responses from 780,000 to 709.700. There is no
change to the burden time per response. Although the number of responses
changed, SSA did not take any actions to cause this change.

16.

Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.

17.

Displaying 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.

18.

B.

Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements in 5 CFR
1320.9 and related provisions in 5 CFR 1320.8(b)(3).

Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.

Supporting Statement for Form SSA-3373-BK
Function Report – Adult
20 CFR 404.1512 and 20 CFR 416.912
OMB No. 0960-0681
A.

Justification
1.

Introduction/Authoring Laws and Regulations
Sections 205(a), 223(d)(5)(A), 1631(d)(1), and 1631(e)(1) of the Social Security
Act (Act) require individuals receiving or applying for Social Security disability
insurance (SSDI) or Supplemental Security Income (SSI) to provide medical and
other evidence of their disability. These sections of the Act grant the Social
Security Administration (SSA) the authority to establish procedures for collecting
and verifying this evidence. 20 CFR 404.1512 and 416.912 of the Code of
Federal Regulations provide detailed requirements of the types of evidence Social
Security disability claimants and beneficiaries must provide showing how their
impairment(s) affects their ability to work (e.g., evidence of age; education and
training; work experience; daily activities; efforts to work; and any other
evidence). SSA uses Form SSA-3373-BK, the Function Report-Adult, to collect
the information for adult disability cases.
We are including the Information Collection Requests (ICR) for 0960-0072
(SSA-454; i454); 0960-0144 (SSA-3441; i3441); 0960-0579 (SSA-3368; i3368);
0960-0632 (SSA-3380-BK); and 0960-0681 (SSA-3373-BK), under one new
OMB Control Number, 0960-0XXX for the purposes of obtaining OMB approval
for the revisions we are making to these forms as part of the Rulemaking process
for the Removing the Education Category - Inability to Communicate in English from the Disability Determination Process, RIN 0960-AH86. For technical
purposes, we need to keep the regulatory-related changes to these forms on a
separate track through the publication of the Final Rule stage, as we need to
continue to use these forms, and renew their current OMB approvals, while
simultaneously obtaining approval for the changes due to the revised rules under
RIN 0960-AH86. To ensure we maintain OMB’s approval for the current
versions of the forms, we will maintain this separate OMB number for duration of
the NPRM and Final Rule changes to RIN 0960-AH86. Once we publish the
Final Rule, we will update these forms under their separate OMB Control
Numbers and discontinue the new OMB approval, 0960-0XXX, as we will no
longer require it.
We are making these changes to our Regulations because the education category
“inability to communicate in English” is no longer a reliable indicator of an
individual’s educational attainment or the vocational impact of an individual’s
education. We published the Notice of Proposed Rulemaking, RIN 0960-AH86,
on February 1, 2019, at 84 FR 1006.

2.

Description of Collection
SSA staff, and, on our behalf, State Disability Determination Services’ (DDS)
employees, collect the information via paper Form SSA-3373-BK, or through an
in-person or telephone interview for cases where we need information about a
claimant’s activities and abilities to evaluate the claimant’s disability. We use the
information to document how claimants’ disabilities affect their ability to
function, and to determine eligibility, or continued eligibility, for SSI and SSDI
claims. The respondents are Title II and Title XVI applicants (or current
recipients undergoing redeterminations) for disability payments.

3.

Use of Information Technology to Collect the Information
This form is available as a fillable PDF on SSA’s website, which the respondent
completes, prints, and mails to the DDS or brings to an SSA field office. SSA has
not yet created an electronic version of Form SSA-3373 under the agency’s
Government Paperwork Elimination Act (GPEA) plan due to competing
priorities. DDS offices, operating on several variations of five different legacy
computer systems, each programmed to support state-designed business
processes, conduct 99 percent of these collections. Before SSA can deploy an
electronic version of the SSA-3373, the agency must upgrade and standardize the
DDS case processing systems. We are currently working on a way to update the
DDS case processing systems.

4.

Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect 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 SSA did not collect this information, we would be unable to determine a
claimant’s disability, or the extent of continuing disability; and we would be
unable to fulfill our mandate to make payments to those who are disabled. Since
respondents complete the form only once for an initial application, or on an
occasional basis if selected for a continuing disability review or for an appeal of
our decision, we cannot collect the information 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
SSA published a notice of proposed rulemaking (NPRM) in the Federal Register
on February 1, 2019, at 84 FR 1006. If we receive any comments in response to

the NPRM, we will forward them to OMB. When we publish the Final Rule, we
will re-submit this ICR for formal approval of the information collection
requirements described within.
9.

Payment or Gifts to Respondents
SSA provides no payment or gifts to the respondents, except for the actual
disability payments (if one qualifies for them).

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 OMB 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

SSA-3373-BK

Total
Estimated
Annual
Burden
(hours)
61
1,763,546

Number of
Frequency Average
Respondents of
Burden Per
Response Response
(minutes)
1,734,635

1

The total burden for this ICR is 1,763,546 hours. We based this figure on current
management information data. We did not calculate a separate cost burden.
13.

Annual Cost to the Respondents (Other)
This collection does not cause a known cost burden on the respondents.

14.

Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $3,403,000. This
estimate accounts for costs from the following areas: (1) designing, printing, and
distributing the form; and (2) SSA employee (e.g., field office, 800 number, DDS
staff) information collection and processing time.

15.

Program Changes or Adjustments to the Information Collection Request
The decrease in burden hours from 2,120,483 to 1,763,546 hours stems from a
decrease in initial claims of about 300,000 respondents over the last three years.
We have not changed the time estimate for this collection, nor have we
significantly changed the form; so the average burden per response remains the
same. Our current management information data shows a significant decrease in
the number of initial claims, as well as a fluctuation and decrease in current
continuing disability redeterminations and reconsideration claims which amounts
to this reduction in the burden hours. The reduction in burden also explains the

reduction in the cost to the Federal government, as we are printing and processing
fewer forms now than we did three years ago.

B.

16.

Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.

17.

Displaying 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.

18.

Exceptions 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).

Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.