Disability Report-Appeal 20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 405 subpart C, 422.140

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Supplemental Justification Revised Collection Instrument SSA-3441.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2006-08-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43698	Disability Report-Appeal 20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 405 subpart C, 422.140	Other-Internet Collection Screen	Modified

ICR Details

OMB Control No: 0960-0144	ICR Reference No: 200608-0960-011
Status: Historical Active	Previous ICR Reference No: 200606-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Disability Report-Appeal 20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 405 subpart C, 422.140
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/14/2006
	Date Received in OIRA: 08/23/2006
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2009	36 Months From Approved	08/31/2009
Responses	1,112,720	0	1,112,720
Time Burden (Hours)	924,967	0	924,967
Cost Burden (Dollars)	0	0	0

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Abstract: The SSA-3441-BK is used to secure updated resource and condition information from claimants seeking reconsideration of denied disability benefits. The claimant also has the option of providing the information during a personal interview or through SSA's Internet Application. This information assists the State DDS and ALJ in preparing for appeals and hearings and in issuing a decision. Respondents are individuals who appeal denial of Social Security Disability Income and SSI benefits, cessation of benefits, or who are requesting a.....

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Disability Report-Appeal 20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 405 subpart C, 422.140

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ICR Summary of Burden

table that charts list of burden

	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	1,112,720	1,112,720	0	0	0	0
Annual Time Burden (Hours)	924,967	924,967	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/23/2006

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