Report of Adult Functioning-Employer

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-3385-BK Report of Adult Functioning-Employer	Form	Modified	Repair queued
Justification for the Non-Substantive Changes 0805.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-07-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
221156	Report of Adult Functioning-Employer	Form	Modified

ICR Details

OMB Control No: 0960-0805	ICR Reference No: 201706-0960-008
Status: Historical Active	Previous ICR Reference No: 201604-0960-014
Agency/Subagency: SSA	Agency Tracking No:
Title: Report of Adult Functioning-Employer
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/28/2017
	Date Received in OIRA: 07/12/2017
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2019	10/31/2019	10/31/2019
Responses	3,900	0	3,900
Time Burden (Hours)	1,300	0	1,300
Cost Burden (Dollars)	0	0	0

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Abstract: Section 205 (a), 223 (d) (5) (A), 1631(d) (1), and 1631 (e) (1) of the Social Security Act (Act) require claimants’ applying for Social Security Disability Insurance or Supplemental Security Income benefits to provide SSA with medical and other evidence of their disability. 20 CFR 404.1512 and 20 CFR 416.912 of the Code of Federal Regulations provides detailed requirements of the types of evidence Social Security disability claimants and beneficiaries must provide showing how their impairment(s) affects their ability to work (e.g., evidence of age, education and training, work experience, daily activities, efforts to work, and any other evidence). Past employers familiar with the claimant’s ability to perform work activities completes Form SSA-385-BK, Report of Adult Functioning-Employer to provide SSA with information about the employees day-to-day functioning in the work setting. SSA and Disability Determination Services use the information Form SSA-3385-BK collects as the basis to determine eligibility or continued eligibility for disability benefits. The respondents are claimants’ past employers. We are creating a fillable, printable version of the SSA-3385.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 1381 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:
	81 FR 24927	04/27/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 43691	07/05/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Report of Adult Functioning-Employer	SSA-3385-BK	Report of Adult Functioning-Employer

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ICR Summary of Burden

table that charts list 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	3,900	3,900	0	0	0	0
Annual Time Burden (Hours)	1,300	1,300	0	0	0	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:

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Annual Cost to Federal Government: $8,644

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 07/12/2017

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