Report on Individual with Mental Impairment

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-824 Report on Individual with Mental Impairment--Private Sector	Form	Modified	Available
Form SSA-824 Report on Individual with Mental Impairment--State DDSs	Form	New	Available
Addendum to Supporting Statement - 0058.doc	Supplementary Document	Uploaded 2009-01-12	Available
Supporting Statement--0058.doc	Supporting Statement A	Uploaded 2009-01-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8976	Report on Individual with Mental Impairment--Private Sector	Form	Modified
186032	Report on Individual with Mental Impairment--State DDSs	Form	New

ICR Details

OMB Control No: 0960-0058	ICR Reference No: 200808-0960-002
Status: Historical Active	Previous ICR Reference No: 200512-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Report on Individual with Mental Impairment
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: 02/25/2009
	Date Received in OIRA: 01/12/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2012	36 Months From Approved	02/28/2009
Responses	50,000	0	50,000
Time Burden (Hours)	30,000	0	30,000
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA uses the SSA-824 to obtain medical evidence from medical sources that have treated the claimant for a mental impairment. SSA uses the information collected on this form to establish whether a claimant filing for disability benefits has a mental impairment that meets the statutory definition of disability in the Act. The respondents are mental treatment facilities.

---

Authorizing Statute(s): US Code: 42 USC 423 Name of Law: null
   US Code: 42 USC 1382c Name of Law: null
  

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:
	73 FR 49730	08/22/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 75491	12/11/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Report on Individual with Mental Impairment--Private Sector	SSA-824	Report on Individual with Mental Impairment
Report on Individual with Mental Impairment--State DDSs	SSA-824	Report on Individual with Mental Impairment

---

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	50,000	50,000	0	0	0	0
Annual Time Burden (Hours)	30,000	30,000	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: There are no changes in the public reporting burden. However, prior to ROCIS we were unable to create separate ICs for the types of respondents (Private Sector and State DDSs). We have created separate ICs within this ICR to show each of the types of respondents individually.

---

Annual Cost to Federal Government: $904,000

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: 01/12/2009

---