Disability Report-Appeal

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-3441-BK Disability Report--Appeal	Form	Unchanged	Repair queued
Form i3441 (iAppeals) Disability Report--Appeal (i3441--Revisions to the Screening Questions for Use with the New iAppeals Program)	Form and Instruction	Modified	Available
Form i3441 Disability Report--Appeal	Form and Instruction	Modified	Repair queued
Form SSA-3441-BK (EDCS Disability Report--Appeal (EDCS Screens)	Form	Unchanged	Available
Supplemental Information on i3441 - 12-4-2008[1).doc	Supplementary Document	Uploaded 2007-12-04	Available
Statement of Explanation of the Change in Burden Estimate for the i3441 final(R) - 10-26.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2007-10-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43698	Disability Report-Appeal (Paper Version)	Form	Unchanged	Disability Report--Appeal
180152	Disability Report--Appeal (Internet Version)	Form and Instruction	Modified	Disability Report--Appeal (i3441--Revisions to the Screening Questions for Use with the New iAppeals Program)
180152	Disability Report--Appeal (Internet Version)	Form and Instruction	Modified	Disability Report--Appeal
180152	Disability Report--Appeal (Internet Version)	Instruction	Modified
180151	Disability Report--Appeal (EDCS)	Form	Unchanged	Disability Report--Appeal (EDCS Screens)

ICR Details

OMB Control No: 0960-0144	ICR Reference No: 200710-0960-006
Status: Historical Active	Previous ICR Reference No: 200705-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Disability Report-Appeal
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 with change	Conclusion Date: 12/04/2007
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/26/2007
Terms of Clearance: This change request is approved consistent with supplemental information provided by SSA. The most recent version of the Welcome Screen revision (11/9/07) shall be used.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2010	08/31/2010	08/31/2010
Responses	1,463,908	0	1,463,908
Time Burden (Hours)	1,058,280	0	1,296,190
Cost Burden (Dollars)	0	0	0

---

Abstract: The SSA-3441-BK is used to secure updated medical and other information since the claimant’s last disability determination from claimants who are appealing an unfavorable disability determination. This information may be used for reconsideration or request for federal reviewing official review of initial disability determinations and continuing disability reviews as well as a request for a hearing. This information assists the State Disability Determination Services, federal reviewing officials, and administrative law judges in preparing for appeals and hearings and in issuing a decision. Respondents are individuals who appeal denial of Social Security disability income and Supplemental Security Income (SSI) benefits, cessation of benefits, or who are requesting a hearing.

---

Authorizing Statute(s): US Code: 42 USC 405
   US Code: 42 USC 423
   US Code: 42 USC 1383
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 14845	03/29/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 35293	06/27/2007
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Disability Report--Appeal (EDCS)	SSA-3441-BK (EDCS Screens)	Disability Report--Appeal (EDCS Screens)
Disability Report--Appeal (Internet Version)	i3441, i3441 (iAppeals)	Disability Report--Appeal ,   Disability Report--Appeal (i3441--Revisions to the Screening Questions for Use with the New iAppeals Program)
Disability Report-Appeal (Paper Version)	SSA-3441-BK	Disability Report--Appeal

---

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	1,463,908	1,463,908	0	0	0	0
Annual Time Burden (Hours)	1,058,280	1,296,190	0	0	-237,910	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: Please see Supplementary section of the Internet 3441 IC (last IC in the list)for a revised Welcome page showing our new burden estimate. Attached to this ICR is a document discussing the data we used to arrive at this new burden estimate.

---

Annual Cost to Federal Government: $14,287,941

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

---

Common Form ICR:  No

---

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: 10/26/2007

---