Addendum to the Supporting Statement 0960-0578

Addendum to the Supporting Statement for

Form SSA-3369-BK

Work History Report

CFR 404.1512, 416.912, 404.1560, 404.1565, 416.960 and 416.965

OMB 0960-0578

Terms of Clearance

This ICR is approved on the understanding that SSA will, within the next 36

months and prior to renewal of this ICR, convene two focus groups of (a) disability adjudicators and (b) SSA claimants/benes{sic}. Anecdotal evidence suggests that claimants have difficulty with the parts of this form that ask them to break down their daily work activities by the hour (i.e. "in this job, how many total hours each day did you crouch, kneel, stoop," etc.). In turn, SSA adjudicators may need to follow-up with claimants to get the information they need because they could not obtain it through the form. The purpose of these focus groups will be to evaluate the utility of this question and to assess the extent to which utility could be improved. SSA agrees to ask adjudicators questions such as "how ofen {sic} is the information provided on this form incomplete, unreliable, or otherwise inadequate, requiring you to follow-up with the claimant to get the information required?" Questions to be asked of claimants include questions like "how easy or difficult do you find this question to answer?"

SSA Response

Upon further review, SSA determined there was no need to convene focus groups to evaluate the usability of the SSA-3369. The SSA disability components have used the SSA-3369 for many years and have never had any issues or problems arise regarding how the form is completed. Field office personnel and Disability Determination Services adjudicators and reviewers who constantly deal with the public have not voiced any concerns nor have they had any complaints from claimants, third parties, or authorized representatives about having any difficulties in understanding or completing the questions on the SSA-3369. SSA anecdotal evidence suggest that claimants find the questions help jog their memory on recalling past work experience. If respondents do have questions about the form or need help completing it, there are clear instructions on the cover page of the form for them to call the SSA representative for assistance in completing the form. The SSA-3369 design is easy to read and follow so that people can complete it in a timely manner.

Minor Revisions to the Collection Instrument

SSA is making the following revisions:

SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the first page of the form.