Rachel,
� Why did SSA choose to incorporate the pain report into this form rather than creating a new form?
Currently, there is no national adult �symptoms� form. As a result, there has been no uniformity in the format or the questions used to collect information about symptoms in adult disability claims since the SSA-3370-BK (Pain Report � Adult) was removed from circulation in 1997. (The SSA-3370-BK was formally obsoleted in August 2001.) Since 1997, when information about the functional effects of an adult claimant�s symptoms on his or her ability to work is needed, each disability determination services (DDS) uses its own forms and questions to collect this information. To correct the lack of national uniformity, we had promised OMB in 2004, in generic clearance package 0960-0555, that we would create a new national form to collect information about symptoms.
Rather than create an additional form, we are revising the SSA-3373-BK (Function Report � Adult) to collect information about the functional effects of a claimant�s physical or mental impairment-related symptom(s). This revision will provide a single form to collect and record information about the functional effects of a claimant�s illnesses, injuries, or conditions and related symptoms on his or her activities and abilities. The information collected by the revised
SSA-3373-BK, together with medical evidence, is part of the evidentiary basis upon which the initial disability process is founded. The revised SSA-3373-BK reduces the paperwork the claimant has to complete and the adjudicator has to review, and will reinstate national uniformity in the collection of information we need to assess disability for adult claimants under the title II and title XVI disability programs.
� SSA is revising this form, in part to make the questions readily convertible to an electronic format when the time comes. When does SSA expect to make that transition? How does this timing fit with SSA's request for three years of OMB approval?
The form's new format gives it the capability of being electronically scanned for data collection. It is not a fully electronic, fillable document, accessible to the public. The form can be downloaded and printed for use as a paper form. There are no plans , at this time, to make this form a fillable electronic form in the next three years.
� SSA is increasing the burden estimate to one hour in response to public comments that 30 minutes was not enough time to complete the form. However, SSA is also adding new questions to this form as a result of the revision - specifically a number of questions on pain. If one hour is sufficient for the information on the old form, what should the addition of new questions bring the burden estimate to? Also, we wanted to note that the increase in the burden estimate is currently listed in ROCIS as "Due to Agency Discretion," rather than to an "adjustment" of burden hours, which appears to be incorrect. Please indicate the number of hours that SSA would like to have as "due to agency discretion" and as an "adjustment" and OMB will make the changes in the system when approval is granted.
The 30 minute increase in the time it takes to complete this form is the result of a combination of public input and the addition of new questions. The burden estimate for the State pain form was 15 minutes. So, we added 15 minutes to this form for the addition of pain questions "due to agency discretion" 15 as an "adjustment" due to public comment.
Liz
Davidson
SSA
Reports Clearance Officer
DCFAM,
OPLM, OPUM
410-965-0454
Pager:
410-909-8175
Fax:
410-965-6400
From: Potter,
Rachel F. [mailto:[email protected]]
Sent: Monday, October 16, 2006 10:09
AM
To: Davidson,
Liz
Subject: OMB comments on
Function Report - Adult (0960-0681)
Liz -
OMB has the following comments on the subject collection (0960-0681):
� Why did SSA choose to incorporate the pain report into this form rather than creating a new form?
� SSA is revising this form, in part to make the questions readily convertible to an electronic format when the time comes. When does SSA expect to make that transition? How does this timing fit with SSA's request for three years of OMB approval?
� SSA is increasing the burden estimate to one hour in response to public comments that 30 minutes was not enough time to complete the form. However, SSA is also adding new questions to this form as a result of the revision - specifically a number of questions on pain. If one hour is sufficient for the information on the old form, what should the addition of new questions bring the burden estimate to? Also, we wanted to note that the increase in the burden estimate is currently listed in ROCIS as "Due to Agency Discretion," rather than to an "adjustment" of burden hours, which appears to be incorrect. Please indicate the number of hours that SSA would like to have as "due to agency discretion" and as an "adjustment" and OMB will make the changes in the system when approval is granted.
Please respond no later than noon on Wednesday 10/18. Thanks!
Rachel F. Potter
Office of Information and Regulatory
Affairs
Office of Management and Budget
Tel: (202) 395-5887
Fax: (202) 395-6974
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