Questionnaire for Children Claiming SSI Benefits

Forms and Documents

Document	Type	Status	Availability
Form SSA-3881 BK Questionnaire for Children Claiming SSI Benefits	Form	Modified	Repair queued
SSA-3881 Supporting Statement 042507.doc	Supporting Statement A	Uploaded 2007-05-09	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
9392	Questionnaire for Children Claiming SSI Benefits	Form	Modified

ICR Details

OMB Control No: 0960-0499	ICR Reference No: 200612-0960-011
Status: Historical Active	Previous ICR Reference No: 200404-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Questionnaire for Children Claiming SSI Benefits
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/23/2007
	Date Received in OIRA: 05/11/2007
Terms of Clearance: Approved for one year only because the explanation for not providing an electronic version of the form is not satisfactory. Given the large number of respondents who use this form, the ability to submit these forms electronically should be a priority, on a par similar to other forms SSA has made available electronically due to the volume of their use. Upon resubmission of this form for OMB approval, SSA will either make this form electronically available or provide a detailed justification of why the agency was not able to make the form electronically available. The justification should go well beyond simply asserting that it is not an agency priority and include a timeframe when SSA expects the form will become available electronically.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2008	36 Months From Approved	07/31/2007
Responses	253,000	0	253,000
Time Burden (Hours)	126,500	0	126,500
Cost Burden (Dollars)	0	0	0

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Abstract: An applicant completes this form on behalf of a child when appealing an unfavorable disability decision or when a child's continuing entitlement to SSI disabled child's benefits is being reviewed. The form requests the names and addresses of non-medical sources such as schools, counselors, agencies, organizations or therapists who would have information about a child's functioning. It is used by the State Disability Determination Service who may request information from these sources to help make a determination.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: null
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 357	01/04/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 26443	05/09/2007
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Questionnaire for Children Claiming SSI Benefits	SSA-3881 BK	Questionnaire for Children Claiming SSI Benefits

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ICR Summary 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	253,000	253,000	0	0	0	0
Annual Time Burden (Hours)	126,500	126,500	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: $1,558,480

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: 05/11/2007

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