A. Justification
Introduction/Authoring Laws and Regulations
Sections 223(d)(5)(A) and 1631(e)(1) of the Social Security Act (Act) provide that individuals 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 inform us about, or submit all, evidence known relating to being blind or disabled, and if asked furnish evidence of age; education and training; work experience; efforts to work; and any other evidence showing how their impairments affect 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 individuals about work they did in the past. If individuals 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 give 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 asks individuals applying for disability about work they performed in the past. Applicants use Form SSA-3369, Work History Report, to provide SSA with detailed information about applicant’s jobs held prior to becoming unable to work. State Disability Determination Services evaluate the information, together with medical evidence, to determine eligibility for disability payments. The respondents are disability applicants and third parties assisting applicants.
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 paper Form SSA-3369 for applicants who have held more than one job, except in situations where we can make the disability determination without an individual’s complete work history. SSA scans or fax the fillable PDF File into the respondent’s electronic case folder.
In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an Internet version of form SSA-3369. Based on our data, we estimate approximately 30% of respondents under this OMB number use the electronic version.
Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it precludes 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.
Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-3369, we would be unable to determine whether claimants are disabled, and could not discharge our mandate to pay benefits to disabled claimants. Because we only collect the information once, we 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
The 60-day advance Federal Register Notice published on February 21, 2017, at
82 FR 11293, and we received no public comments. The 30-day FRN published on April 26, 2017 at 82 FR 19304. If we receive any comments in response to this 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 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.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
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 |
The total burden for this ICR is 1,591,949 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
13. Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden on the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $112,476. This estimate is a projection of the costs for printing and distributing the collection instrument, and for collecting the information using paper forms, which includes printed PDF file forms.
For the EDCS, the estimated cost to the Federal Government to collect the information is negligible for the electronic version. Because we account for the cost of maintaining the system which collects this information within the cost of maintaining all of SSA’s automated systems, it is not possible to calculate the cost associated with just one Internet application.
15. Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.
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 Form 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 | Mandley, Tasha |
| File Modified | 2017-05-02 |
| File Created | 2017-01-30 |