Parents or legal guardians seeking to
obtain or retain SSI eligibility for their children use Form
SSA-3881-BK to provide SSA with the addresses of non medical
sources such as schools, counselors, agencies, organizations, or
therapists who have information about a child’s function. The
adjudicative team (a disability examiner and a medical or
psychological consultant) of the State disability determination
services (DDS) office collects the information to help determine a
child’s claim or continuing eligibility for SSI. The respondents
are the parents, guardians, and other caretakers of applicants who
appeal SSI childhood disability decisions, or of recipients
undergoing a continuing disability review.
US Code:
42
USC 1383 Name of Law: Social Security Act
When we last cleared this
information collection in 2021, the burden was 62,500 hours.
However, we are currently reporting a burden of 75,622 hours. This
change stems an increase in the number of responses from 125,000 to
151,243. 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. These figures represent current
Management Information data. SSA is unable to breakdown the method
in which the form was completed, whether it was completed
electronically (internet) via in-office or telephone appointment or
if it was a paper version submitted to the FO upon completion,
which was then scanned into the electronic file. Therefore, unlike
the information collection in 2021, this information collection is
unable to precisely predict how many respondents physically
traveled to the FO. At the prior information collection for this
form (2021), we determined that approximately 65% of respondents
visited the FO to submit a paper version of the SSA-3881-BK. We are
continuing to use that data; however, we are still working on a
better way to obtain more accurate data to make this estimate. *
Note: The total burden reflected in ROCIS is 246,905, while the
burden cited in #12 of the Supporting Statement is 75,622. This
discrepancy is because the ROCIS burden reflects the following
components: field office waiting time + a rough estimate of a
30-minute, one-way, drive burden + learning costs. In contrast, the
chart in #12 of the Supporting Statement reflects actual
burden.
$2,127,813
No
Yes
Yes
No
No
No
No
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-3881 BK Questionnaire for Children Claiming SSI Benefits - Paper Version
Supporting Statement - 0499 (Final).docx
Questionnaire for Children Claiming SSI Benefits - Paper Version