Supporting Statement 0720 SSA-3830 102708 revised[1]

Certification of Low Birth Weight for SSI Eligibility (SSA-3830)

20 CFR 416.931, 416.926a(m) (7) & (8) and 416.924

OMB # 0960-0720

1. Justification

1. Section 1633 of the Social Security Act (the Act) allows the Commissioner of Social Security to make appropriate or necessary administrative and other arrangements to carry out the functions of the Agency under Title XVI of the Act. Section 1614 of the Act provides the rules under which the Social Security Administration (SSA) makes disability determinations for individuals under age 18. 20 CFR 416.931 of the Code of Federal Regulations provides that the Social Security Administration may pay benefits before we make a formal finding of disability if we find that the claimant is presumptively disabled. 20 CFR 416.926a(m) (7) and (8) provide that certain low birth weigh infants are considered disabled at least until they attain age 1. 20 CFR 416.924 provides the rules for a formal determination of disability in a childhood case.

2. Form SSA-3830 assists hospitals and claimants who file on behalf of children in providing local field offices (FOs) and Disability Determination Services (DDSs) with medical information for determining disability of low birth weight infants. FOs use the forms as protective filing statements, and the medical information for making presumptive disability findings, which allow expedited payment to eligible claimants. DDSs use the medical information to determine disability and the most appropriate continuing disability review diaries. The respondents are hospitals that have information identifying low birth weight babies and medical conditions those babies may have.

3. Due to low volume of usage and other Agency priorites, Form SSA-3830 is not available electronically.

4. The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to collect similar data.

5. This collection does not have a significant impact on a substantial number of small businesses or other entities. The information required is minimal and readily available from hospital records.

6. SSA must use the information on Form SSA-3830 to determine disability claims based on low birth weight. The consistency of information for low birth weight claims would decrease if the SSA-3830 form were not available, because non-standardized field office requests for medical information would vary, resulting in longer or shorter requests from hospital to hospital. This would be less efficient, less reliable, and less clear for purposes of quality assurance and any other reviews. Since SSA collects this information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles that prevent burden reduction.

7. There are no special circumstances that would cause this information collection to be conducted in a manner that is not consistent with 5 CFR § 1320.5.

8. The 60-day advance Federal Register Notice published on January 15, 2009, at 74 FR 2642, and SSA received no public comments. The second Notice published on April 07, 2009, at 7 FR 15808. There have been no outside consultations with members of the public.

The Federal Register Notice lists this ICR as an extension: however, as we are revising the Privacy Act Statement, SSA is not listing this ICR as a revision.

9. SSA provides no payment or gifts to the respondents.

10. The information provided on this form is protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.

11. The information collection does not contain any questions of a sensitive nature.

12. Approximately 24,000 respondents use this form. The estimated completion time is 15 minutes. Thus, the total burden is 6,000 hours. The total burden represents burden hours, and SSA did not calculate separate cost burden.

13. There is no known cost burden to the respondents.

14. The annual cost to the Federal government is approximately $36,960. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. There are no changes in the public reporting burden.

16. SSA will not publish the results of the information collection.

17. OMB exempted SSA from the requirement to print the OMB approval expiration date on its program forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB approval. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). OMB granted this exemption so the agency would not have to discontinue using otherwise useable editions of forms with outdated expiration dates. In addition, SSA avoids Government waste, because we will not have to destroy and reprint stocks of forms.

18. SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA is not using statistical method for this collection.