Supporting Statement - 0540

Supporting Statement for Form SSA-3371-BK

Pain Report-Child

20 CFR 416.912, 404.512

OMB No. 0960-0540

A. Justification

1. Introduction/Authoring Laws and Regulations

Sections 1614 (a)(3)(H)(i) and 1631(e)(1) of the Social Security Act (Act) require claimants for SSA benefits to furnish medical and other evidence of disability as required to prove their disability. Disability regulations in 20 CFR 416.912 and 404.512 require individuals to provide medical evidence and, if asked, evidence of age; education; training; work experience; daily activities; efforts to work; and any other evidence showing how their impairment(s) affects the ability to work or, in the case of a child, how the claimant functions. Section 1631(d)(1) of the Act provides the Commissioner of the Social Security Administration (SSA) with the full power and authority to make rules and regulations, establish procedures, and to adopt reasonable and proper rules for the nature and extent of the evidence as well as the methods of taking and furnishing the same to evaluate the alleged disability. The Social Security Administration (SSA) uses Form SSA-3371-BK to record information about pain or other systems of a child who is claiming disability.

2. Description of Collection

Before SSA can make a disability determination for a child, we require evidence from Supplemental Security Income (SSI) applicants or claimants to prove their disability. Form SSA-3371-BK provides disability interviewers, and SSI applicants or claimants in self-help situations, with a convenient way to record information regarding the claimant’s pain, or other symptoms. The State disability determination services adjudicators and administrative law judges then use the information from Form

SSA-3371-BK to assess the effects of symptoms on function for purposes of determining disability under the Act. The respondents are applicants for, or claimants of, SSI payments.

3. Use of Information Technology to Collect the Information

SSA did not create an electronic version of Form SSA-3371-BK under the agency’s Government Paperwork Elimination Act due to higher volume forms taking precedence. When funds are available in the future, we plan to create an electronic version of Form SSA-3371-BK.

3. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it preclude duplication. SSA does not use another collection instrument to obtain similar data.

5. 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

If we did not use Form SSA-3371-BK, we would not be able to pay SSI to disabled claimants, as it would be impossible to determine if claimants were truly disabled. Because we collect the information every time a claimant files for SSI, 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.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on October 15, 2018, at

83 FR 52042, and we received no public comments. The 30-day FRN published on December 26, 2018 at 83 FR 66330. 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 revision of this form.

9. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the 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

Modality of Collection	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-3371	250,000	1	15	62,500

The total burden for this ICR is 62,500. We base these figures on current management information data. 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 to the respondents.

14. Annual Cost to Federal Government

The annual cost to the Federal Government is approximately $1,540,000. This

Estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; and (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time.

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.

16. Displaying 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.

16. 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.