Addendum 0960-0681F

ADDENDUM TO THE SUPPORTING STATEMENT FOR FORM SSA-3373-BK

OMB NO. 0960-0681

Revision to the Information Collection Instrument

SSA requests that the revised SSA-3373 (Function Report- Adult) OMB approved on 10/17/06 be rescinded and that the previous version of this form be reinstated. SSA has reevaluated the kind of information disability adjudicators need to make a decision and how SSA collects that information. This evaluation raises policy, litigation, and usability concerns that lead SSA to request this rescission.

Policy and Litigation Concerns

In connection with the usability issues identified in the following section, SSA is examining its regulations and other policy guidance regarding collection of information from claimants in support of allegations made about symptoms, including pain. To document a claimant’s symptoms, SSA policy requires information about, among other things, any factors concerning the individual’s functional limitations and restrictions due to pain or other symptoms. To this end, the version of form SSA-3373 that OMB approved on 10/17/06 requests specific information about how a claimant’s symptoms affect his or her ability to function. Unfortunately, many of these questions are structured similarly to the SSA‑4734 (Physical Residual Functional Capacity Assessment) (0960-0431), which is the Agency’s administrative assessment of the claimant’s residual functional capacity (RFC). It is possible that these questions on the SSA‑3373 have the appearance of asking a claimant to assess his or her RFC. It is our belief that this appearance of similarity between the questions on the SSA‑4734 and the SSA‑3373 would leave the Agency at substantial risk of litigation when the claimant’s assessment of his or her RFC does not exactly match the Agency’s findings on the SSA‑4734.

As a result and in connection with the usability studies discussed below, the Agency is planning to revise these questions on the SSA‑3373 so that they are not structured similarly to the SSA‑4734. In the meantime, SSA does not want to expose itself to an additional cause for litigation, and so requests that the version of form SSA‑3373 OMB approved on 10/17/06 be rescinded.

Usability Issues

SSA has acquired new information about differences in beneficiary responses, depending on the type of format provided for the response.

In June 2007, SSA performed usability testing on a draft version of a similar form,¹ the SSA‑454, with beneficiaries. The results of this test indicate that beneficiaries have difficulty with responses that must be entered in a check box format, that is, they didn’t see them, didn’t understand them, and didn’t complete them. The usability testing results indicate that beneficiary response is more complete and accurate when the response is entered in a text box.

The SSA-3373 is a benefits form that is completed by claimants. It contains questions requiring descriptive information about the claimant’s activities and socialization that will permit judgments about the quality, effectiveness, independence, appropriateness, and sustainability of those activities and relationships. The most recently revised SSA-3373 that OMB approved on 10/17/06 marked a shift from the previous version of the SSA-3373 by including more questions in a check box format. That is, it consists of 2 pages of instructions and 15 pages containing 20 questions. There are a total of 242 check boxes and 54 text boxes. We believe that the previous version of the SSA-3373 will elicit more complete and accurate information since it relies less on check box format questions. It consisted of 2 pages of instructions and 8 pages containing 21 questions. There were a total of 99 check boxes and 55 text boxes.

As can be seen, we learned a great deal from usability testing of a major disability form in

June 2007. We will reevaluate the form SSA-3373 with the goal of reducing the number of check boxes on the form. Also, we will conduct usability testing and then resubmit the form for OMB approval. We anticipate that a revised form will improve our information collection capability, reduce the burden on the public, and better support the disability adjudication process in the future.

Symptoms Questions

The form that OMB approved on 10/17/06 included symptoms questions. The prior version of the SSA-3373 did not because the State DDSs were collecting this information under OMB No. 0960-0555. Because we are asking to temporarily reinstate the prior version of the SSA-3373, the DDSs will need to collect symptoms information using its forms while we work on developing and testing a better revised form. The revised form will include symptoms questions, so that we have a national standardized form. Upon OMB approval of the revised form, we will eliminate DDS collection of symptoms information under information collection 0960-0555.

1 The SSA-3373 is similar to the SSA-454 in that the target population is similar (i.e., beneficiaries and claimants) and the topic is similar (i.e., information related to a disabling impairment).