Function Report - Adult

ICR 201207-0960-005

OMB: 0960-0681

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2012-09-24
Supplementary Document
2012-09-24
IC Document Collections
IC ID
Document
Title
Status
9735 Modified
ICR Details
0960-0681 201207-0960-005
Historical Active 200905-0960-008
SSA
Function Report - Adult
Revision of a currently approved collection   No
Regular
Approved without change 11/28/2012
Retrieve Notice of Action (NOA) 09/27/2012
  Inventory as of this Action Requested Previously Approved
11/30/2015 36 Months From Approved 11/30/2012
4,221,656 0 4,005,367
4,292,017 0 4,072,123
0 0 0

SSA uses Form SSA-3373-BK to collect information about a disability applicant's or recipient's impairment-related limitations and ability to function. This information, together with medical evidence, forms the evidentiary basis upon which the initial disability process is founded. The respondents are title II and title XVI applicants(or current recipients undergoing redeterminations for) disability benefits.

US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 42 USC 405 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  77 FR 40401 07/09/2012
77 FR 58903 09/24/2012
No

1
IC Title Form No. Form Name
Function Report - Adult SSA-3373 Function Report -- Adult

  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 4,221,656 4,005,367 0 0 216,289 0
Annual Time Burden (Hours) 4,292,017 4,072,123 0 0 219,894 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
When we last cleared this information collection in 2009, the burden was 4,072,123 hours. However, we are currently reporting a burden of 4,292,017 hours. This change stems from an increase in the number of respondents. The increase in the number of respondents reflects an increase in claims for disability benefits.

$39,003,879
No
No
No
No
No
Uncollected
Faye Lipsky 410 965-8783 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
09/27/2012


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