Function Report - Adult

ICR 200608-0960-008

OMB: 0960-0681

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2006-10-16
Supplementary Document
2006-08-18
Supporting Statement A
2006-08-18
IC Document Collections
IC ID
Document
Title
Status
9735 Modified
ICR Details
0960-0681 200608-0960-008
Historical Active 200310-0960-012
SSA
Function Report - Adult
Revision of a currently approved collection   No
Regular
Approved without change 10/17/2006
Retrieve Notice of Action (NOA) 08/21/2006
This form is a potential electronic candidate under SSA's GPEA implementation plan. SSA plans to evaluate this form for electronic conversion within the next few years. OMB approves this form with the understanding that upon resubmission of this form for OMB approval, SSA will have completed this evaluation and will provide OMB with a full report of the results of the evaluation.
  Inventory as of this Action Requested Previously Approved
10/31/2009 36 Months From Approved 12/31/2006
4,005,367 0 4,005,367
4,005,367 0 2,002,684
0 0 0

Form SSA-3373-BK is used to collect information about a disability applicant's or recipient's impairment-related limitations and ability to function. This information, together with medical evidence, forms the evidentiary basis upon which the initial disability process is founded. The respondents are Title II and Title XVI applicants(or current recipients undergoing redeterminations for) disability benefits.

US Code: 42 USC 405 Name of Law: null
   US Code: 42 USC 423 Name of Law: null
   US Code: 42 USC 1383 Name of Law: null
  
None

Not associated with rulemaking

  71 FR 30464 05/26/2006
71 FR 45090 08/08/2006
No

1
IC Title Form No. Form Name
Function Report - Adult SSA-3373-BK, SSA-3373 Function Report - Adult (Current Version with no Revisions) ,   Function Report - Adult (Version with Proposed Revisions)

  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 4,005,367 0 0 0 0
Annual Time Burden (Hours) 4,005,367 2,002,684 0 1,001,342 1,001,341 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
The increase in response time and resulting total burden is due to 1) complaints SSA received that its original estimate was too low and 2) the fact that we have added a number of new questions to this form (see attached addendum for detailed explanations).

$37,009,591
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Elizabeth Davidson 411-965-0454 [email protected]

  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.
08/21/2006


© 2024 OMB.report | Privacy Policy