Report on Individual with Mental Impairment

Forms and Documents

Document	Type	Status	Availability
Form SSA-824 Report on Individual with Mental Impairment--Private Sector	Form	Modified	Available
Form SSA-824 Report on Individual with Mental Impairment--State DDSs	Form	Modified	Repair queued
0058 Supporting Statement.docx	Supporting Statement A	Uploaded 2011-11-07	Available
Addendum.doc	Supplementary Document	Uploaded 2011-10-31	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
8976	Report on Individual with Mental Impairment--Private Sector	Form	Modified
186032	Report on Individual with Mental Impairment--State DDSs	Form	Modified

ICR Details

OMB Control No: 0960-0058	ICR Reference No: 201107-0960-005
Status: Historical Active	Previous ICR Reference No: 200808-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Report on Individual with Mental Impairment
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: 12/12/2011
	Date Received in OIRA: 11/10/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	36 Months From Approved	02/29/2012
Responses	500	0	50,000
Time Burden (Hours)	300	0	30,000
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the SSA-824 to obtain medical evidence from medical sources that have treated the claimant for a mental impairment. SSA uses the information collected on this form to establish whether a claimant filing for disability benefits has a mental impairment that meets the statutory definition of disability under the Social Security Act. The respondents are mental treatment sources or facilities.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 1382c Name of Law: Social Security Act
  

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:
	76 FR 45902	08/01/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 68805	11/07/2011
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Report on Individual with Mental Impairment--State DDSs	SSA-824	Report on Individual with Mental Impairment
Report on Individual with Mental Impairment--Private Sector	SSA-824	Report on Individual with Mental Impairment

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ICR Summary 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	500	50,000	0	0	-49,500	0
Annual Time Burden (Hours)	300	30,000	0	0	-29,700	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: Since last we cleared this information collection, the DDS offices have changed their business processes for acquiring this information. They have found it more cost effective to use the medical evidence of record process as outlined in the OMB-approved information collection OMB No. 0960-0555, Clearance of Information Collections Conducted by State Disability Determination Services on Behalf of the Social Security Administration.

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Annual Cost to Federal Government: $7,500

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: 11/10/2011

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