Physical Residual Functional Capacity Assessment/Mental Residual Capacity Assessment

Forms and Documents

Document Name	Status
Form SSA-4734-BK Physical Residual Functional Capacity Assessment and Mental Residual Capacity Assessment Form	Modified
Supporting Statement--0431.doc Supporting Statement A	0000-00-00

IC Document Collections

IC ID	Document Title	Status
9288	Physical Residual Functional Capacity Assessment and Mental Residual Capacity Assessment Form	Modified

ICR Details

OMB Control No: 0960-0431	ICR Reference No: 200701-0960-005
Status: Historical Active	Previous ICR Reference No: 200404-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Physical Residual Functional Capacity Assessment/Mental Residual Capacity Assessment
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 with change	Conclusion Date: 05/07/2007
	Date Received in OIRA: 02/15/2007
Terms of Clearance: Approved consistent with SSA clarifications on 4/23/07 and 5/3/07. SSA shall circulate the final version of the form with a material change as agreed on 4/23/07.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2010	36 Months From Approved	05/31/2007
Responses	2,397,646	0	2,421,865
Time Burden (Hours)	799,215	0	807,288
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected on form SSA-4734-BK and SSA-4734-F4-SUP is needed by SSA to assist in the adjudication of disability claims involving physical and/or mental impairments. The forms assist the State DDS offices to evaluate the severity of impairments by providing standardized data collection forms. The use of these forms by the DDSs ensures nationally consistent evaluations presented in a concise, clear and readily understandable manner. The respondents are primarily doctors in DDSs funded and administered by SSA.

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Authorizing Statute(s): US Code: 42 USC 1383b Name of Law: null
   US Code: 42 USC 421 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:
	71 FR 75607	12/15/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 7107	02/14/2007
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
Physical Residual Functional Capacity Assessment and Mental Residual Capacity Assessment	SSA-4734-BK, SSA-4734-F4-SUP	Physical Residual Functional Capacity Assessment ,   Mental Residual Functional Capacity Assessment

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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	2,397,646	2,421,865	0	0	-24,219	0
Annual Time Burden (Hours)	799,215	807,288	0	0	-8,073	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: The public reporting burden of 799,215 hours represents a 1% decrease in burden hours. This burden change is due to a decrease in the number of case dispositions since the last clearance in 2003.

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Annual Cost to Federal Government: $76,181,186

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: 02/15/2007

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