Child-Care Dropout Questionnaire

Forms and Documents

Document Name	Status
Form SSA-4162 Child-Care Dropout Questionnaire Form	Modified
Addendum - 0474.docx Supplementary Document	2019-07-23
Supporting Statement - 0474.docx Supporting Statement A	2019-07-29

IC Document Collections

IC ID	Document Title	Status
9367	Child-Care Dropout Questionnaire Form	Modified

ICR Details

OMB Control No: 0960-0474	ICR Reference No: 201903-0960-006
Status: Active	Previous ICR Reference No: 201602-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Child-Care Dropout Questionnaire
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/16/2019
	Date Received in OIRA: 07/29/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2022	36 Months From Approved	09/30/2019
Responses	2,000	0	2,000
Time Burden (Hours)	167	0	167
Cost Burden (Dollars)	0	0	0

---

Abstract: The basic Social Security disability benefits application form (cleared under OMB No. 0960-0618) contains a lead question asking if the applicant cared for their own or their spouse’s children under age 3, and had no earnings during that period. If the answer is yes, the applicant completes Form SSA-4162 (either on paper or through a Social Security Administration (SSA) claims representative (CR) during a personal interview). SSA uses the information to determine if the applicant qualifies for the child-care exclusion. For the modernized claims system (MCS) application version, the beneficiary provides the information verbally to the SSA CR during a personal interview, and the CR inputs the information directly into the MCS application. The CR prints the MCS application for the beneficiary to verify and sign. Respondents are applicants for Title II disability benefits.

---

Authorizing Statute(s): US Code: 42 USC 415 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 18913	05/02/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 34469	07/18/2019
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Child-Care Dropout Questionnaire	SSA-4162	Child-Care Dropout Questionnaire

---

ICR Summary 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	2,000	2,000	0	0	0	0
Annual Time Burden (Hours)	167	167	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:

---

Annual Cost to Federal Government: $9,000

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

---

Common Form ICR:  No

---

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: 07/29/2019

---