Child-Care Dropout Questionnaire

ICR 201903-0960-006

OMB: 0960-0474

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2019-07-23
Supporting Statement A
2019-07-29
IC Document Collections
IC ID
Document
Title
Status
9367 Modified
ICR Details
0960-0474 201903-0960-006
Active 201602-0960-007
SSA
Child-Care Dropout Questionnaire
Revision of a currently approved collection   No
Regular
Approved without change 09/16/2019
Retrieve Notice of Action (NOA) 07/29/2019
  Inventory as of this Action Requested Previously Approved
09/30/2022 36 Months From Approved 09/30/2019
2,000 0 2,000
167 0 167
0 0 0

The basic Social Security disability benefits application form (cleared under OMB No. 0960-0618) contains a lead question asking if the applicant cared for their own or their spouse’s children under age 3, and had no earnings during that period. If the answer is yes, the applicant completes Form SSA-4162 (either on paper or through a Social Security Administration (SSA) claims representative (CR) during a personal interview). SSA uses the information to determine if the applicant qualifies for the child-care exclusion. For the modernized claims system (MCS) application version, the beneficiary provides the information verbally to the SSA CR during a personal interview, and the CR inputs the information directly into the MCS application. The CR prints the MCS application for the beneficiary to verify and sign. Respondents are applicants for Title II disability benefits.

US Code: 42 USC 415 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  84 FR 18913 05/02/2019
84 FR 34469 07/18/2019
No

1
IC Title Form No. Form Name
Child-Care Dropout Questionnaire SSA-4162 Child-Care Dropout Questionnaire

  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 2,000 2,000 0 0 0 0
Annual Time Burden (Hours) 167 167 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$9,000
No
    Yes
    Yes
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.
07/29/2019


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