Non-Substantive Change Request for 0960-0144

Justification for Non-Substantive Changes for Form SSA-3441-BK

Disability Report - Appeal

20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 422.140, 404.1713, 416.1513, 404.1740(b)(4), 416.1540(b)(4), and 20 CFR 405, Subpart C

OMB No. 0960-0144

Background

As part of our initial disability determination reconsideration and hearings appeals process, we require individuals to submit both an appeal form (either the SSA-561/i561, Request for Reconsideration, OMB Control No. 0960-0622; or the HA-501/i501, Request for Hearing, OMB # 0960-0269) along with the SSA-3441/i3441, Disability Report – Appeal (OMB # 0960-0144). Individuals can complete either the paper or the Internet versions of these applications. For the Internet versions, the iAppeals application is available on the www.ssa.gov website, and the respondent can complete the appeal over the Internet. The iAppeals application also includes the i561 (Request for Reconsideration; OMB # 0960-0622), i520 (Request for Review of Hearing Decision/Order; OMB# 0960-0277) and i3441 (Disability Report - Appeal; OMB # 0960‑0144). Respondents must complete the paper SSA-3441 or the Internet i3441 when an applicant wishes to appeal an unfavorable disability determination.

To ensure we obtain all of the information we need to process an appeal submitted through iAppeals, we implemented the single submission process in March 2015. Single submission requires individuals to complete and simultaneously submit the appeal request (i561 or i501) and Disability Report (i3441) to file an appeal on an initial disability determination through iAppeals. To ensure individuals understand the requirements for filing a reconsideration or hearing for an initial disability determination through iAppeals, we provide a detailed Terms of Service (TOS) page and ask respondents to acknowledge they read and understood the TOS for using iAppeals to file an appeal. We have alert language throughout iAppeals that explains when an individual did not submit an appeal, and details the requirements for submitting an appeal. We also have a “Submit” tab that identifies the need for an individual to take an action to submit an appeal.

The revisions we made to the i3441 (electronic form) required a change, for consistency purposes only, to the EDCS 3441-BK and SSA-3441-BK forms. The detailed list for revisions to all three forms is below.

Revisions to the Collection Instrument – i3441

• Change #1: We hyphenated the word “re-entry” on the following screens.

  • Getting Ready Screen: What you need to know before you begin

  • Identification Screen

  • Save and Exit Screen

  • Return to a Saved Appeal Screen

  • Forgot or Lost Re-entry Number Screen

Justification #1: We hyphenated the word re-entry to make the spelling of it consistent with how we spell it in our iClaims application and, thereby, more familiar to respondents.

• Change #2: We revised the Terms of Service Screen, in the I Acknowledge section, bullet #4 – we added language about the Submit button on the Submit tab (shown on the Attach Files screen)

Justification #2: We added information about the Submit tab because it is a new tab and further alerts respondents of the need to take the action of selecting the Submit button in order to file their appeal requests with us.

• Change #3: We added “Your appeal request has not been submitted and it will not be processed at this time” to the Save and Exit Screen.

Justification #3: We added this language to ensure that the respondents understand that if they exit the application, at this point, that they have not submitted their appeal request and, thus, we will not process it.

• Change #4: We added, “‘Yes I want to Exit’ saves the information you have entered for your appeal request and allows you to complete and submit your appeal request later” to the Save and Exit Screen.

Justification #4: We added this language to ensure the respondents understand that they may save the information they already entered for their appeal requests, but they will need to return to iAppeals and finish entering the information for the appeal request to submit the appeal request.

• Change #5: We added the Submit tab.

Justification #5: We added the Submit tab to alert respondents that they will need to access it to select the Submit button to submit their appeal requests.

• Change #6: We renamed the Review screen “Summary Review.”

Justification #6: We added the word Summary to alert respondents that the information provided on the screen is a summary of the information they entered for the appeal request, and to give them the opportunity to review and, if necessary, edit the information before submitting the appeal request to us.

• Change #7: We moved the alert message to the top of the Summary Review screen and added information about the Submit tab to the alert message.

Justification #7: We moved the alert message to top of the screen to alert respondents, at the beginning of the screen, that they have not submitted their appeal requests and it is time to review and, if necessary, edit their information. Once the respondents complete the review, they will need to select the Submit tab and select the Submit button to submit an appeal request.

• Change #8: We placed the Attach Files screen under the Submit tab.

Justification #8: We placed the Attach Files screen behind the Submit Tab because the last thing that a respondent does is attach evidence, and submit it with the appeal request.

• Change #9: We added information about how to submit paper evidence to the Attach Files screen.

Justification #9: We added information about how to submit paper evidence so respondents know they are not limited to submitting electronic evidence only. In addition, the respondents also know they still may gather and submit additional evidence later if they need to do so.

• Change #10: We updated the alert message at bottom Attach Files screen that explains the Submit button and Save and Exit button.

Justification #10: We added the language to alert respondents that we will not process their appeal requests until they select the Submit button and, thereby, submit the appeal to us. We added language that explains to respondents that if they select to Save and Exit, they have not submitted the appeal request to us and the information they entered will temporarily remain in iAppeals.

• Change #11: We added “previously described” before “physical or mental conditions” in the following section: Changes in Conditions Screen (2)

Justification #11: This change better guides respondents to provide information about how their conditions have changed, rather than all information about their conditions, even those that were previously described.

• Change #12: We added “new or updated” in the following sections:

  • Treatment Dates with this Doctor or Healthcare Provider (2)

  • Medical Conditions Treated by This Doctor or Healthcare Provider (2)

Justification #12: This change better guides respondents to include new or updated information about their conditions rather than all information about their conditions, even those previously submitted.

• Change #13: We added “ALL” before “prescription and non-prescription” in the following sections:

  • Medicines Recommended or Prescribed by this Doctor or Healthcare Provider Screen

  • Medicines Screen

Justification #13: This change better guides respondents to include all prescription and non-prescription medicines instead of those related to their conditions only.

Revisions to the Collection Instrument – EDCS-3441

• Change #1: We added “previously described” before “physical or mental condition” in the following sections:

• 3441 Medical Conditions Screen. The sentence should read “Since you last told us about your medical conditions, has there been any CHANGE (for better or worse) in your previously described physical or mental conditions.”

• 3441 Activities Screen. The sentence should read “Since you last told us about your activities, has there been any change (for better or worse) in your previously described daily activities due to your physical or mental conditions?”

Justification #1: This change better guides respondents to provide information about how their conditions have changed, rather than all information about their conditions, even those that were previously described.

• Change #2: On the 3441 Medical Sources screen, we added “or updated” after “NEW” in the sentence “Tell us who may have NEW medical records…”

• Justification #2: This change guides respondents to include updated information in addition to new medical records.

Revisions to the Collection Instrument – SSA-3441-BK

• Change #1: We added “previously described” before “physical or mental conditions” in the following section: changes in Conditions section

Justification #1: This change better guides respondents to provide information about how their conditions changed, rather than all information about their conditions, even those that were previously described.

• Change #2: In the Medical Treatment section, we added “new or updated” to two sentences in #4. The sentences should read:

  • First: What new or updated medical conditions were treated or evaluated?

  • Second: What new or updated treatment did you receive for the above conditions? (Do not list medicines in this box.)

Justification #2: This change better guides respondents to include new or updated information about their treatment and conditions rather than all information about their treatment and conditions, even those previously submitted.

• Change #3: In Question #7 of the Activities section, we added “previously described” before “daily activities”

• Justification #3: This change better guides respondents to provide information about how their daily activities have changed, rather than all information about their daily activities, even those that were previously described.

SSA will implement these changes to the i3441, EDCS-3441, and SSA-3441-BK upon OMB approval.

These actions do not affect the public reporting burden.

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