Supporting Statement--0681

SUPPORTING STATEMENT FOR FORM SSA-3373-BK

FUNCTION REPORT-ADULT

20 CFR 404.1512 and 20 CFR 416.912

OMB No. 0960-0681

A. Justification

1. Sections 205(a), 223(d), 1631(d)(1), and 1631(e) (1) of the Social Security Act mandate that disability claimants and beneficiaries must provide medical evidence and any other proof that the Social Security Administration (SSA) requires to prove their disability. 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations provide detailed requirements, stating that disability claimants and beneficiaries must provide evidence of age, education and training, work experience, daily activities, efforts to work, and any other evidence showing how his or her impairment(s) affects the ability to work. We developed a collection instrument to gather this required information. Form SSA-3373-BK, the Function Report-Adult, is the instrument used to accomplish this for adult disability claimants and beneficiaries.

2. The information collected by form SSA-3373 is used by the State disability determination services (DDS) to document how claimants’ alleged disabilities or beneficiaries’ disabilities affects their ability to function. SSA uses this information, together with medical evidence, as the basis to determine eligibility or continued eligibility for disability benefits.

3. Form SSA-3373-BK is not available in an electronic format because SSA has had to devote its limited resources to other, more urgent electronic projects that our claimants use more frequently. As noted earlier, the State DDSs use this form. The DDS mails this form to the respondent. DDS does not have the systems access that will accept Internet data. However, SSA plans to reevaluate this form for electronic conversion within the next few years.

4. SSA does not collect duplicate information. There is no other collection instrument used by SSA that collects data similar to that collected here.

5. This collection does not affect small businesses or other small entities.

5. If SSA did not collect this information, it would be impossible to determine whether claimants are disabled or beneficiaries are still disabled, and SSA would not be able to discharge its mandate to pay benefits to those who are disabled. Since the form is completed only once for an initial application and on an occasional basis if a beneficiary is selected for a continuing disability review or participates in an appeals hearing, the information cannot be collected less frequently. There are no technical or legal obstacles that prevent burden reduction.

5. There are no special circumstances that would cause SSA to conduct this information collection in a manner that is not consistent with 5 CFR 1320.5.

5. The 60-day advance Federal Register Notice published on May 21, 2009, at 74 FR 23916, and SSA has received no public comments. The second Notice published on July 27, 2009 at 74 FR 37081. There have been no outside consultations with members of the public.

5. SSA provides no payment or gifts to the respondents, except for the actual disability payments (if one qualifies for them).

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

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

5. Approximately 4,005,367 respondents with a response time of 61 minutes complete form SSA-3373-BK. The total burden is therefore 4,072,123 burden hours per annum. SSA gives the total burden in burden hours, and has calculated no separate cost burden. All respondents are individuals.

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

5. The annual cost to the Federal Government is approximately $37,009,591. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

5. 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.

5. SSA will not publish the results of the information collection will not be published.

5. OMB has granted SSA an exemption from printing the 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 that otherwise useable editions of could continue to be used. In addition, we avoid Government waste because SSA would not destroy and reprint stocks of forms.

5. 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. Collection of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

2