Supporting Statement 0960-0720

Supporting Statement for

Certification of Low Birth Weight for SSI Eligibility (SSA-3830)

20 CFR 416.931, 416.926a(m) (7) & (8) and 416.924

OMB No. 0960-0720

1. Justification

1. Introduction/Authoring Laws and Regulations - Section 1633 of the Social Security Act (Act) allows the Commissioner of the Social Security Administration (SSA) to make appropriate or necessary administrative and other arrangements to carry out the functions of the agency under title XVI of the Act. Section 1614 of the Act provides the rules under which SSA makes disability determinations for individuals under age 18. Section 20 CFR 416.931 of the Code of Federal Regulations allows SSA to pay benefits before making a formal finding of disability if we find the claimant is presumptively disabled. Section 20 CFR 416.926a(m) (7) and (8) provide that certain low birth weight infants are considered disabled at least until they attain age 1. Section 20 CFR 416.924 describe the rules for a formal determination of disability in a childhood case.

2. Description of Collection - SSA uses Form SSA-3830 (Certification of Low Birth Weight for SSI Eligibility) to collect information from hospitals to assist claimants who are filing for disability payments on behalf of a child. Hospitals complete this voluntary information collection on a one-time basis. The form documents birth weight and other medical information about low birth weight babies. Field offices may use the form as a protective filing statement and for making presumptive disability findings, which allow expedited payment to eligible claimants. State Disability Determination Services use the medical information to determine disability, and to establish the most appropriate time for evaluating a child’s continued disability.

3. Use of Information Technology to Collect the Information - SSA did not create an electronic version of Form SSA-3830 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only approximately 27,500 respondents complete the form. This is less than the GPEA cut-off of 50,000.

4. Why We Cannot Use Duplicate Information - The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to collect similar data.

5. Minimizing Burden on Small Respondents - This collection does not affect small businesses or other small entities.

6. Consequences of Not Collecting Information or Collecting it Less Frequently - If we did not use the Form SSA-3830, non-standardized field office requests for medical information would vary, resulting in longer or shorter requests from hospital to hospital. This would be less efficient, less reliable, and less clear for purposes of quality assurance and other reviews. Because we collect this information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to prevent burden reduction.

7. Special Circumstances - There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public- SSA published the 60-day Federal Register Notice on January 3, 2012 at 77 FR 147, and we did not receive any public comments. We published the 30-day Federal Register Notice on March 19, 2012 at 77 FR 16113. If we receive any comments in response to the 30-day Notice, we will forward them to OMB.

9. Payment of Gifts to Respondents - SSA does not provide payments or gifts to respondents.

10. Assurances of Confidentiality - SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

11. Justification for Sensitive Questions - The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden - Approximately 27,500 respondents take 15 minutes each to complete Form SSA-3830. Accordingly, the burden is 6,875 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents - This collection does not impose a known cost burden on the respondents.

14. Annual Cost to the Federal Government - The annual cost to the Federal Government is approximately $42,350. This estimate is a projection of the costs for printing and distributing the collection instrument, and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request – The public reporting burden has increased due to an increase in respondents.

16. Plans for Publication Information Collection Results - SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date - OMB granted SSA an exemption from the requirement to print the OMB approval expiration date on its program forms. SSA produces millions of public-use forms, with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

18. Exception to Certification Statement - 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. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.