Function Report - Adult

ICR 200905-0960-008

OMB: 0960-0681

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2009-06-26
Supporting Statement A
2009-07-28
IC Document Collections
IC ID
Document
Title
Status
9735 Modified
ICR Details
0960-0681 200905-0960-008
Historical Active 200708-0960-018
SSA
Function Report - Adult
Revision of a currently approved collection   No
Regular
Approved without change 11/06/2009
Retrieve Notice of Action (NOA) 07/31/2009
  Inventory as of this Action Requested Previously Approved
11/30/2012 36 Months From Approved 08/31/2011
4,005,367 0 4,005,367
4,072,123 0 4,005,367
0 0 0

SSA uses Form SSA-3373-BK to collect information about a disability applicant's or recipient's impairment-related limitations and ability to function. This information, together with medical evidence, forms the evidentiary basis upon which the initial disability process is founded. The respondents are Title II and Title XVI applicants(or current recipients undergoing redeterminations for) disability benefits.

US Code: 42 USC 423 Name of Law: null
   US Code: 42 USC 1383 Name of Law: null
   US Code: 42 USC 405 Name of Law: null
  
None

Not associated with rulemaking

  74 FR 23916 05/21/2009
74 FR 37081 07/27/2009
No

1
IC Title Form No. Form Name
Function Report - Adult SSA-3373 Function Report -- Adult

  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 4,005,367 4,005,367 0 0 0 0
Annual Time Burden (Hours) 4,072,123 4,005,367 0 66,756 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
There is a change in the public reporting burden. On our prior Form-SSA-3373, we erroneously noted that we estimated that it would take 30 minutes to read the instructions, gather the facts and answer the questions. This was a typographical error. We intended to indicate that it would take 60 minutes to complete the form. We moved two questions from the SSA-3368 (Disability Report) to the SSA-3373. This change resulted in a one-minute increase in the burden per response.

$37,009,591
No
No
Uncollected
Uncollected
No
Uncollected
Elizabeth Davidson 411-965-0454 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
07/31/2009


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