Work History Report

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-3369 Work History Report	Form and Instruction	Modified	Available
Supporting Statement 0578.docx	Supporting Statement A	Uploaded 2010-11-29	Available
addendum.doc	Supplementary Document	Uploaded 2010-11-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9542	Work History Report	Form and Instruction	Modified
181136	Work History Report (EDCS)	Other-EDCS	Modified

ICR Details

OMB Control No: 0960-0578	ICR Reference No: 201007-0960-005
Status: Historical Active	Previous ICR Reference No: 200803-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Work History Report
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/06/2011
	Date Received in OIRA: 12/10/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2014	36 Months From Approved	04/30/2011
Responses	1,697,468	0	449,500
Time Burden (Hours)	1,697,468	0	449,500
Cost Burden (Dollars)	0	0	0

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Abstract: SSA collects the information to document an applicant's work history. The Disability Determination Services adjudicators use the information to make a decision about the alleged disability. The respondents are applicants for disability benefits.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Disability Insurance Benefits
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 45692	08/03/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 71785	11/24/2010
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Work History Report	SSA-3369	Work History Report
Work History Report (EDCS)

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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	1,697,468	449,500	0	0	1,247,968	0
Annual Time Burden (Hours)	1,697,468	449,500	0	0	1,247,968	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: The increase in the public burden is twofold: economic downturn has dramatically increased the number of respondents since we last cleared this ICR; secondly, we were inadvertently counting some of the respondents for this form under the SSA-3368 (i3368 Internet and the electronic disability collect system, OMB #0960-0579).

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Annual Cost to Federal Government: $24,672

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 12/10/2010

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