Function Report - Adult

ICR 200310-0960-012

OMB: 0960-0681

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
9735 Migrated
ICR Details
0960-0681 200310-0960-012
Historical Active
SSA
Function Report - Adult
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 12/12/2003
Retrieve Notice of Action (NOA) 10/31/2003
  Inventory as of this Action Requested Previously Approved
12/31/2006 12/31/2006
4,005,367 0 0
2,002,684 0 0
0 0 0

Form SSA-3373 is used to obtain the types of information specified in the regulations and to provide disability interviewers with a convenient means to record information about how the claimant's condition affects his or her ability to function. The DDS evaluator uses the information to assess the alleged disability. This information, together with medical evidence, forms the evidentiary basis upon which the initial disability process is founded.

None
None


No

1
IC Title Form No. Form Name
Function Report - Adult SSA-3373

  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 4,005,367 0 0 4,005,367 0 0
Annual Time Burden (Hours) 2,002,684 0 0 2,002,684 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
10/31/2003


© 2024 OMB.report | Privacy Policy