Disability Report - Child

Forms and Documents

Document Name	Status
Form SSA-3820-BK Disability Report - Child (Paper) SSA-3820 Form	Modified
Supporting Statement - 0577.docx Supporting Statement A	2019-09-20
Addendum to Supporting Statement 0577.docx Supplementary Document	2019-09-19

IC Document Collections

IC ID	Document Title	Status
9538	Disability Report - Child (Paper) SSA-3820 Form	Modified
179519	Disability Report - Child (Internet) Other-Disability Report - Child (Internet)	Modified
179518	Disability Report - Child (EDCS) Other-EDCS	Modified

ICR Details

OMB Control No: 0960-0577	ICR Reference No: 201906-0960-006
Status: Received in OIRA	Previous ICR Reference No: 201807-0960-014
Agency/Subagency: SSA	Agency Tracking No:
Title: Disability Report - Child
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/20/2019

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2021
Responses	355,144	399,466
Time Burden (Hours)	621,502	659,431
Cost Burden (Dollars)	0	0

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Abstract: SSA uses Form SSA-3820-BK to collect information about a child’s condition from treating sources or other medical sources of evidence. The State Disability Determination Services (DDS) evaluators use the information from Form SSA-3820-BK to develop medical and school evidence, and to assess the alleged disability. The information, together with medical evidence, forms the evidentiary basis upon which SSA makes its initial disability evaluation. The respondents are claimants seeking SSI childhood disability payments. Applicants can complete and print Form SSA-3820-BK and mail to SSA, or take the notification page (generated after completing the i3820) to their local Social Security field office (FO). The notification page serves as a back-up alert to the FOs that an applicant transmitted an internet disability report. When claimants do not complete an i3820, FO employees use the Electronic Disability Collect System (EDCS) internal collection process to key information provided by claimants onto EDCS screens to establish a database for the DDS adjudicators We are revising language on the SSA-3820-BK and the i3820 Internet application screens to change Mental Health/Retardation Center to Mental health/Developmental Disabilities Center due to a statuary change in terminology.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 1383 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:
	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

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Disability Report - Child (Paper) SSA-3820	SSA-3820-BK	Disability Report - Child
Disability Report - Child (Internet)
Disability Report - Child (EDCS)

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ICR Summary of Burden

	Total Request	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	355,144	399,466	0	0	-44,322	0
Annual Time Burden (Hours)	621,502	659,431	0	0	-37,929	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 IC in 2016, the burden was 659,431 hours. However, we are currently reporting a burden of 621,502 hours. This change stems a decrease in the number of responses from 659,431 to 621,502. 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.

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Annual Cost to Federal Government: $751,220

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? No

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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: 09/20/2019

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