Disability Report - Adult, 20 CFR 404.1512 and 416.912

Forms and Documents

Document Name	Status
Form SSA-3368 Disability Report - Adult, 20 CFR 404.1512 and 416.912 (Paper) Form and Instruction	Modified
0960-0579-OMB Passback (2).doc Supplementary Document	2008-01-30
SSA-3368 page 10 revision-word.doc Supplementary Document	2008-01-30
3368 supporting statement.doc Supporting Statement A	2007-08-02
3368 Addendum.doc Supplementary Document	2007-07-12

IC Document Collections

IC ID	Document Title	Status
9548	Disability Report - Adult, 20 CFR 404.1512 and 416.912 (Paper) Form and Instruction	Modified
179421	Disability Report - Adult, 20 CFR 404.1512 and 416.912 (PRO) Other-i3368 PRO	Modified
179420	Disability Report - Adult, 20 CFR 404.1512 and 416.912(Internet) Other-SSA-3368 (Internet)	Modified
179419	Disability Report - Adult, 20 CFR 404.1512 and 416.912 (EDCS) Other-EDCS	Modified

ICR Details

OMB Control No: 0960-0579	ICR Reference No: 200708-0960-002
Status: Historical Active	Previous ICR Reference No: 200704-0960-003
Agency/Subagency: SSA	Agency Tracking No:
Title: Disability Report - Adult, 20 CFR 404.1512 and 416.912
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/01/2008
	Date Received in OIRA: 08/02/2007
Terms of Clearance: This ICR is approved consistent with the 12-19-07 memo and the agreed-upon revisions to the instrument to minimize respondent burden. Although this ICR has undergone numerous revisions in the past, the revisions have not been substantive enough to make previous editions obsolete. As per the 12-19-07 memo, previous versions of this form continue to be used until the stock is used up. For this reason, SSA is not required to print the expiration date for the OMB control number on these forms. However, should this form undergo more substantive changes in the future, SSA agrees to consider printing the expiration date on the forms.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2011	36 Months From Approved	01/31/2008
Responses	3,350,554	0	2,116,667
Time Burden (Hours)	3,552,823	0	2,257,667
Cost Burden (Dollars)	0	0	0

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Abstract: The Disability Report-Adult collects medical and other evidence which is used to determine whether an adult's impairment is disabling, and consequently, if that adult is entitled to Title II and/or Title XVI disability payments from the Social Security Administration. The information can be collected through the following ways: a paper form, in an SSA field office, an Internet version, and a new Internet version designed to be completed by professional advocacy groups. The respondents are adult disability applicants or their representatives.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: null
   US Code: 42 USC 423 Name of Law: null
   US Code: 42 USC 405 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 20154	04/23/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 32697	06/13/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Disability Report - Adult, 20 CFR 404.1512 and 416.912 (EDCS)
Disability Report - Adult, 20 CFR 404.1512 and 416.912(Internet)
Disability Report - Adult, 20 CFR 404.1512 and 416.912 (Paper)	SSA-3368	Disability Report - Adult, 20 CFR 404.1512 and 416.912
Disability Report - Adult, 20 CFR 404.1512 and 416.912 (PRO)

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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	3,350,554	2,116,667	0	1,233,887	0	0
Annual Time Burden (Hours)	3,552,823	2,257,667	0	1,295,156	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There is an increase in the public reporting burden since this was last approved by OMB. The change is due to several factors. A major factor is that we have been able to compile more accurate data since we prepared the previous Supporting Statement. Other factors are increased use of the EDCS 3368, i3368 and i3368-PRO, and the additional time it takes respondents to use the i3368 and i3368-PRO over the time it takes for use of the EDCS 3368 and paper SSA-3368.

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Annual Cost to Federal Government: $34,708,811

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: 08/02/2007

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