Addendum 0960-0681

ADDENDUM TO THE SUPPORTING STATEMENT FOR FORM SSA-3373-BK

FUNCTION REPORT-ADULT

20 CFR 404.1512 and 20 CFR 416.912

OMB No. 0960-0681

Revision to the Collection Instrument

SSA is adding two questions to this revised SSA-3373 (Function Report – Adult). Upon OMB approval, these two questions will be removed from the SSA-3368 (Disability Report Adult) and will be asked on the SSA-3373.

We have decided that these questions should be asked on the SSA-3373 because they are not needed to begin development and can be asked later in the disability decision process.

The two questions that we are adding to this collection are:

• How do your illnesses, injuries, or other conditions limit your ability to work?

• Do you currently take any medicines for your illnesses, injuries, or conditions? If “Yes,” do any of your medicines cause side effects? If “Yes,” please explain.

We have added a new section “Information about Illnesses, Injuries, or Conditions” for the first question. We did this because this question did not fit logically into the other sections.

We placed the question related to medicines at the end of the forms so that the claimant can easily list additional side effects in the “Remarks” section which follows.

Once OMB approves the revised SSA-3368, these questions will no longer be asked on that form. Although we do not believe that we need this information to begin development, we do think these are important questions to ask of many claimants later in the case development process. Therefore, SSA will be obsoleting the previous version of the SSA-3373 and will be destroying existing stock.

Justification for Resubmission of the Collection within One Year of OMB Approval

We were unable to make these revisions to this collection as part of our previous submission to OMB, because these changes are necessitated by changes to the SSA-3368, and so we were unable to foresee the need for these changes at the time of the last approval date. We must make these revisions immediately, so that these questions are still asked once OMB approves the revised SSA-3368 which will no longer include these questions.