Supporting Statement - 0720

Supporting Statement for Form SSA-3830

Certification of Low Birth Weight for SSI Eligibility

20 CFR 416.924, 416.926, and 416.931

OMB No. 0960-0720

1. Justification

1. Introduction/Authoring Laws and Regulations

Section 1633 of the Social Security Act (Act) allows the Social Security Administration (SSA) to make appropriate or necessary administrative and other arrangements to carry out the functions of the agency under Title XVI of the Act. Section 1614 of the Act provides the rules under which SSA makes disability determinations for individuals under age 18. Section 20 CFR 416.931 of the Code of Federal Regulations allows SSA to pay benefits before making a formal finding of disability if we find the claimant is presumptively disabled. Sections 20 CFR 416.926a(m)(7) and (8) provide that we consider certain low birth weight infants disabled at least until they attain age 1. Section 20 CFR 416.924 describes the rules for a formal determination of disability in a childhood case.

2. Description of Collection

Hospitals and claimants use Form SSA-3830 to provide medical information to local field offices (FOs) and Disability Determinations Services (DDSs) on behalf of infants with low birth weight. FOs use the form as a protective filing statement, and the medical information to make presumptive disability findings, which allow expedited payment to eligible claimants. DDSs use the medical information from the SSA-3830 to determine disability and continuing disability. The respondents are hospitals and claimants who have information identifying low birth weight babies and their medical conditions.

3. Use of Information Technology to Collect the Information

The form is available as a printable fillable PDF on SSA’s website. Respondents complete the form and return it back to the prefilled address on the top of page one. This collection does not currently have a fully public-facing Internet version, as we prioritized other information collections for full electronic conversions.  As per our 4/3/20 conversation with OIRA, we welcome OIRA to join our conversations with OMB on IT Mods; however, as our IT Mod programming is an ongoing project, we cannot provide timelines for when we will be able to make any particular ICR available via the Internet.  We will convert existing ICRs to full electronic versions depending on how they fall within our overall IT Mod schema, but this is unconnected to the PRA approval lifecycle.

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. Consequences of Not Collecting Information or Collecting it Less Frequently

If we did not use Form SSA-3830, non-standardized field office requests for medical information would vary, resulting in longer or shorter requests from hospital to hospital. This would be less efficient, less reliable, and less clear for purposes of quality assurance and other reviews. Because we collect this information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to prevent 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 November 27, 2020 at 85 FR 76142, and we received no public comments. The 30-day FRN published on January 28, 2021 at 86 FR 7446. If we receive any comments in response to this Notice, we will forward them to OMB.

9. Payment of 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

Please see the burden chart below:

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollars)*	Total Annual Opportunity Cost (dollars)**
SSA-3380	28,125	1	15	7,031	$61.97*	$435,711**

* We based this figure by averaging the average U.S. worker’s (https://www.bls.gov/oes/current/oes_nat.htm) and General Medical Hospital employee’s hourly wages (https://www.bls.gov/oes/current/oes291215.htm), as reported by Bureau of Labor Statistics data.

** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

The total burden for this information collection request is 7,031 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $435,711. SSA does not charge respondents to complete our applications.

13. Annual Cost to the Respondents (Other)

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

14. Annual Cost to the Federal Government

The annual cost to the Federal Government is approximately $212,055.  This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars*
Designing and Printing the Form	Design Cost + Printing Cost	$75
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$800
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$210,930
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0
Systems Development, Updating, and Maintenance	GS-9 employee x man hours for development, updating, maintenance	$250
Quantifiable IT Costs	Any additional IT costs	$0
Total		$212,055

* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have.  It is difficult for us to break down the cost for processing a single form, as field office staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent.  As well, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

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

OMB granted SSA an exemption from the requirement to print the OMB approval 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. Exception 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).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.