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
A. Justification
Introduction/Authoring Laws and Regulations
Sections 223(d)(5)(A) and 1631(e)(1) of the Social Security Act (Act) provide that claimants must furnish medical and other evidence to prove they are disabled. Implementing disability regulations at 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations state individuals must furnish medical evidence and, if asked, furnish evidence of age, education and training, work experience, efforts to work, and any other evidence showing how their impairment(s) affects their ability to work. 20 CFR 404.1560, 404.1565, 416.960, and 416.965 of the Code of Federal Regulations explain that under certain circumstances, the Social Security Administration (SSA) may ask claimants about work they have done in the past. If claimants cannot give us all of the information we need to make a determination, we will attempt to obtain, with their permission, the information from employers or other persons who may know the individuals’ work history, such as family members or co-workers. Sections 205(a) and 1631(d)(1) of the Act gives the Commissioner of SSA full power and authority to make rules and regulations, establish procedures, and adopt reasonable and proper rules as to the nature and extent of the evidence, as well as the methods of obtaining and evaluating such evidence, of an alleged disability.
Description of Collection
SSA uses Form SSA-3369-BK (Work History Report) to obtain the information specified in the regulations above. When claimants report having more than one job, we use Form SSA-3369-BK to obtain information about each of the jobs claimants have had in the 15 years prior to becoming unable to work. This form provides disability applicants, as well as third parties assisting the applicant, with a means of recording information about a claimant’s past work.
The information we collect on the SSA-3369 is used by State disability determinations service (DDS) adjudicators to evaluate vocational evidence as required at steps 4 and 5 of the disability determination sequential evaluation process. This collection is voluntary for respondents; however, failure to cooperate or insufficient evidence may result in an unfavorable decision for disability benefits.
We collect the information from respondents using Form SSA-3369. The modalities people use are the paper Form SSA-3369, telephone, interview, or the fillable Intranet/Internet PDF file.
Use of Information Technology to Collect the Information
SSA claims representatives use the electronic disability collect system (EDCS) to directly key in SSA-3369-BK information from applicants who are homeless or will be difficult for State agencies to recontact for another reason. State agencies use the SSA-3369 paper and fillable PDF file forms for applicants who have had more than one job, except in situations where the disability determination can be made without the claimant’s complete work history. The fillable PDF file is printable and like the paper, is electronically faxed or scanned into the respondent’s electronic case folder.
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 obtain similar data.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
6. Consequence of Not Collecting Information or Collecting it Less Frequently
The information we collect on this form is part of the evidentiary basis upon which we process the disability evaluation. This process is a 5-step sequential evaluation and work history is necessary at steps 4 and 5 of the process. If we did not collect the information, we would be unable to determine whether claimants were disabled. If we did not collect this data, SSA could not discharge its mandate to pay benefits to disabled claimants. We only collect the information once and cannot collect it less frequently. There are no technical or legal obstacles to 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.
Solicitation of Public Comment and Other Consultations with the Public
SSA published the 60-day advance Federal Register Notice on December 17, 2013 at 78 FR 76378, and we received no public comments. We published the 30-day Notice on March 3, 2014 at 79 FR 11852. If we receive any comments on the second Notice, we will forward them to OMB. We did not consult with the public in the maintenance of this form.
Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
Assurances of Confidentiality
SSA protects and holds confidential the information we collect 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.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Listed below is the breakdown of the burden hours for the paper SSA-3369 and EDCS.
Modality of Completion |
Number of Respondents |
Frequency of Response |
Average Burden Per Response (minutes) |
Estimated Total Annual Burden (hours) |
SSA-3369 (Paper form) |
1,553,900 |
1 |
60 |
1,553,900 |
SSA-3369 (EDCS) |
38,049 |
1 |
60 |
38,049 |
Totals |
1,591,949 |
|
|
1,591,949 |
13. Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden to the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is $112,476. This is the cost for processing and distributing the collection instrument and collecting the information using paper forms, which includes printed PDF file forms. We account for the cost of maintaining the system that collects this information within the cost of maintaining all of SSA’s automated systems.
15. Program Changes or Adjustments to the Information Collection Request
The public burden has decreased due to a programmatic change that reduced the need for using the collection instrument on some vocational assessments. The DDS adjudicators can skip ahead in the Sequential Evaluation Process to Step 5 without burdening the public with vocational development through the use of the collection instrument, Form SSA-3369, which is used at Step 4. We also have decreased the number of respondents under the IC for EDCS SSA-3369 as we had been incorrectly counting the respondents for this collection method.
16. Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
17. Displaying the OMB Approval Expiration Date
For the paper Form SSA-3369, we will not publish the OMB approval expiration date. OMB granted SSA an exemption from the requirement to print the OMB 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.
For the EDCS SSA-3369, SSA is not requesting an exception to the requirement to display the OMB approval expiration date.
Exceptions 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.
| File Type | application/msword |
| File Title | Title of Information Collection and Form Number(s) |
| Author | Naomi |
| Last Modified By | 889123 |
| File Modified | 2014-03-06 |
| File Created | 2014-01-02 |