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	Available
Addendum - 0805.docx	Supplementary Document	Uploaded 2019-09-23	Available
Supporting Statement - 0805.docx	Supporting Statement A	Uploaded 2019-09-27	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: 201906-0960-001
Status: Active	Previous ICR Reference No: 201811-0960-006
Agency/Subagency: SSA	Agency Tracking No:
Title: Report of Adult Functioning-Employer
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: 12/05/2019
	Date Received in OIRA: 09/27/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2022	36 Months From Approved	12/31/2019
Responses	3,601	0	3,900
Time Burden (Hours)	1,200	0	1,300
Cost Burden (Dollars)	0	0	0

---

Abstract: Individuals receiving or applying for Social Security Disability Insurance or SSI provide SSA with medical evidence and other proof SSA requires to prove their disability. Past employers familiar with the claimant’s ability to perform work activates complete Form SSA-3385-BK, Report of Adult Functioning-Employer, to provide SSA with information about the employee’s day-to-day function in the working setting. We only reach out to past employers when the adjudicative team decides more information is necessary, and that they would be a good source for that information. SSA and Disability Determination Services (DDS) use the information Form SSA-3385-BK collects as a basis to determine eligibility or continued eligibility for disability benefits. The respondents are claimants’ past and current employers.

---

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

---

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 31972	07/03/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 48694	09/16/2019
Did the Agency receive public comments on this ICR? No

---

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

---

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	3,601	3,900	0	0	-299	0
Annual Time Burden (Hours)	1,200	1,300	0	0	-100	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: When we last cleared this information collection (IC) in 2016, the burden was 1,300 hours. However, we are currently reporting a burden of 1,200 hours. This change stems from a decrease in the number of responses from 3,900 to 3,601, which is within the levels of expected fluctuation for this IC. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change.

---

Annual Cost to Federal Government: $8,046

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: 09/27/2019

---