Combined Supporting Statements for English Final Rule - RIN 0960-AH86

Combined Supporting Statements for English Final Rule - RIN 0960-AH86.pdf

Removing Inability to Communicate in English as an Education Category

OMB: 0960-0813

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Supporting Statement for Form SSA-454-BK
Continuing Disability Review Report
20 CFR 404.1589 & 416.989
OMB No. 0960-0072
A.

Justification
1.

Introduction/Authoring Laws and Regulations
Sections 205(a) and 1631(e)(1)(A) of the Social Security Act (Act) provide the
Commissioner of the Social Security Administration (SSA) with full power and
authority to make rules and regulations; establish procedures; and adopt
reasonable and proper procedures governing the nature and extent of the evidence
(as well as the methods of taking and furnishing the same) to determine whether
an individual continues to be disabled. Sections 223(d)(5)(A) and
1614(a)(3)(H)(i) of the Act, as amended, provide that claimants furnish such
medical and other evidence required by the Commissioner to prove they continue
to be disabled. Sections 221(i), 1614(a)(3)(H)(ii)(I) and 1633 (c)(1) of the Act
require us to periodically review the cases of individuals who receive benefits
under Title II or Title XVI of the Act, based on disability, to determine if
disability continues. As provided in 20 CFR 404.1589 and 20 CFR 416.989 of
the Code of Federal Regulations, we may conduct a review to determine whether
benefit entitlement or eligibility continues for individuals receiving disability
benefits.
We are including the Information Collection Requests (ICR) for 0960-0072
(SSA-454; i454); 0960-0144 (SSA-3441; i3441); 0960-0579 (SSA-3368; i3368);
0960-0632 (SSA-3380-BK); and 0960-0681 (SSA-3373-BK), under one new
OMB Control Number, 0960-0813, for the purposes of obtaining OMB approval
for the revisions we are making to these forms as part of the Rulemaking process
for the Removing the Education Category - Inability to Communicate in English from the Disability Determination Process, RIN 0960-AH86. For technical
purposes, we need to keep the regulatory-related changes to these forms on a
separate track through the publication of the Final Rule stage, as we need to
continue to use these forms, and renew their current OMB approvals, while
simultaneously obtaining approval for the changes due to the revised rules under
RIN 0960-AH86. To ensure we maintain OMB’s approval for the current
versions of the forms, we will maintain this separate OMB number for duration of
the NPRM and Final Rule changes to RIN 0960-AH86. The Final Rule published
on February 25, 2020 at 85 FR 10586. Upon OMB’s approval of this ICR, we
will update these forms under their separate OMB Control Numbers and will
discontinue the new OMB approval, 0960-0813, as we will no longer require it.

Description of Collection
SSA uses Form SSA-454-BK (Continuing Disability Review Report) to complete
a mandatory review for the continue disability review (CDR). SSA considers
adults eligible for payment if they continue to be unable to do substantial gainful

activity because of their impairments, and we consider Title XVI children eligible
for payment if they have marked and severe functional limitations because of their
impairments. SSA also uses Form SSA-454-BK to obtain information on sources
of medical treatment; participation in vocational rehabilitation programs (if any);
attempts to work (if any); and to update information if individuals believe their
conditions improved. When a disabled individual requires a CDR, either a claims
representative (CR) mails Form SSA-454-BK; the respondent completes the form
and sends it back to SSA; or the CR interviews the respondent and enters the
information into the Electronic Disability Collection System (EDCS). EDCS
electronically stores the information of the paper version of the Form
SSA-454-BK. The respondents are Title II or Title XVI disability recipients or
their representatives.
3.

Use of Information Technology to Collect the Information
In accordance with the agency’s Government Paperwork Elimination Act plan,
SSA created an Intranet, EDCS, version of Form SSA-454-BK. Based on our
data, we estimate approximately 50% of respondents under this OMB number use
the electronic version as part of a personal interview with a CR.

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.

Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.

Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-454-BK, we would be unable to make a timely
determination regarding if and when recipients should stop receiving disability
payments (either because adults are able to work, or Title XVI children no longer
have marked and severe functional limitations). Because we collect the
information on an as needed basis, we cannot collect it less frequently. There are
no technical or legal obstacles to burden reduction.

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.

Solicitation of Public Comment and Other Consultations with the Public
SSA published a notice of proposed rulemaking (NPRM) in the Federal Register
on February 1, 2019 at 84 FR 1006. We forwarded any comments in response to
the NPRM to OMB. SSA published the Final Rule in the Federal Register on
February 25, 2020 at 85 FR 10586. If we receive any comments in response to
the Final Rule, we will forward them to OMB.

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
Completion

Number of
Frequency
Respondents of
Response

Average
Burden
per
Response
(minutes)

Estimated
Total
Annual
Burden
(hours)

Average
Theoretical
Hourly
Cost
Amount
(dollars)*
270,500
$10.22*

Total Annual
Opportunity
Cost
(dollars)**

SSA-454- BK
270,500
1
60
$2,764,510**
(Paper
version)
EDCS
270,500
1
60
270,500
$10.22* $2,764,510**
Totals
541,000
541,000
$5,529,020**
* We based this figure on average DI payments, as reported in SSA’s disability
insurance payment data.
** This figure does not represent actual costs that SSA is imposing on recipients
of Social Security payments to complete this application; rather, these are
theoretical opportunity costs for the additional time respondents will spend to
complete the application. There is no actual charge to respondents to
complete the application.
The total burden for this ICR is 541,000 burden hours (reflecting SSA
management information data), which results in an associated theoretical (not
actual) opportunity cost financial burden of $5,529,020. SSA does not charge
respondents to complete our applications.
13.

Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden on the respondents.

14.

Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $11,561,710. This
estimate accounts for costs from the following areas: (1) designing, printing, and
distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS
staff) information collection and processing time; and (3) systems development,

updating, and maintenance costs.
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.

17.

Displaying the OMB Approval Expiration Date
For the paper form SSA-454-BK, we will not publish 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.
For the Intranet, EDCS, version of Form SSA-454-BK, SSA is not requesting an
exception to the requirement to display the OMB approval expiration date.

18.

Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements in 5 CFR
1320.9 and related provisions in 5 CFR 1320.8(b)(3).

Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.

Supporting Statement for Form SSA-3441
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
A.

Justification
1.

Introduction/Authoring Laws and Regulations
Sections 205(a), 223(d), and 1631(e) of the Social Security Act (Act), as well as
20 CFR 404.1512 and 416.912 of the Code of Federal Regulations (Code) require
individuals filing for Social Security or Supplemental Security Income (SSI)
benefits based on disability to provide evidence showing how their impairment(s)
affect their ability to work or function. 20 CFR 404.916(c) and 416.1416(c) state
that SSA will include any new evidence applicants submit in connection with
their request for reconsideration in this review. Section 205(b) of the Act, as well
as 20 CFR 405, Subpart C, and 20 CFR 422.140 of the Code, requires the Social
Security Administration (SSA) to provide a reconsideration of an initial denial at
the State Disability Determination Services (DDS) level, and an evidentiary
hearing at the reconsideration appeal level, for individuals who appeal an
unfavorable disability determination. SSA denies the claim when we find the
physical or mental impairment for which such benefits are payable to have
ceased; not to have existed; or not to be disabling. 20 CFR 404.1713 and
416.1513, which include mandatory use of electronic services, as well as 20 CFR
404.1740(b)(4) and 416.1540(b)(4) require a representative requesting direct fee
payment to conduct business with us electronically at the times and in the manner
we prescribe.
We are including the Information Collection Requests (ICR) for 0960-0072
(SSA-454; i454); 0960-0144 (SSA-3441; i3441); 0960-0579 (SSA-3368; i3368);
0960-0632 (SSA-3380-BK); and 0960-0681 (SSA-3373-BK), under one new
OMB Control Number, 0960-0813, for the purposes of obtaining OMB approval
for the revisions we are making to these forms as part of the Rulemaking process
for the Removing the Education Category - Inability to Communicate in English from the Disability Determination Process, RIN 0960-AH86. For technical
purposes, we need to keep the regulatory-related changes to these forms on a
separate track through the publication of the Final Rule stage, as we need to
continue to use these forms, and renew their current OMB approvals, while
simultaneously obtaining approval for the changes due to the revised rules under
RIN 0960-AH86. To ensure we maintain OMB’s approval for the current
versions of the forms, we will maintain this separate OMB number for duration of
the NPRM and Final Rule changes to RIN 0960-AH86. The Final Rule published
on February 25, 2020 at 85 FR 10586. Upon OMB’s approval of this ICR, we
will update these forms under their separate OMB Control Numbers and will
discontinue the new OMB approval, 0960-0813, as we will no longer require it.

Description of Collection
SSA requires disability applicants who wish to appeal an unfavorable disability
determination to complete Form SSA-3441. This form allows claimants to
disclose any changes to their disability or resources that might influence SSA’s
unfavorable determination. SSA may use the information to: (1) reconsider and
review an initial disability determination; (2) review a continuing disability; and
(3) evaluate a request for a hearing. The information SSA requests on the
SSA-3441 facilitates collecting medical and nonmedical information to support
the applicant’s request for reconsideration; request for benefits cessation appeal;
and request for a hearing before an administrative law judge (ALJ). The
information we collect also assists the State DDSs and administrative law judges
(ALJs) in: (1) preparing for the appeals and hearings; and (2) issuing a
determination or decision on an individual’s entitlement (initial or continuing) to
disability benefits. We collect the information via the SSA-3441-BK (paper
form); Electronic Disability Collect System (EDCS); and i3441 Internet screens.
The respondents complete the SSA-3441 by themselves either on paper or online.
If the respondent completes the paper form, they mail it ahead of time or bring it
into the field office (FO) when they have an appointment for an interview, and a
claims representative keys the information into EDCS. If the respondent
completes the i3441, the Field Office uses the information to file the claim.
Respondents are individuals who appeal denial, reduction, or cessation of Social
Security disability income and Supplemental Security Income (SSI) payments;
who are requesting a hearing before an ALJ; or their representatives.

Use of Information Technology to Collect the Information
In accordance with the agency’s Government Paperwork Elimination Act plan,
SSA created two electronic versions of form SSA-3441. SSA designed the
electronic methods to collect the same information as the paper form, but they
may be formatted differently and may include certain enhancements (e.g.,
instructions for claims representatives, help screens, dynamic pathing, etc.) to
guide the interviewer or applicant through the appeal process. Based on our data,
we estimate approximately 97% of the total responses are either collected through
EDCS screens, or via the Internet version of the form (i3441).

Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.

Consequence of Not Collecting Information or Collecting It Less Frequently
If we did not use Form SSA-3441, the public would have no way to apply for
reconsideration, benefits cessation appeal, or for a hearing before an ALJ. This
would violate Sections 221(c) and (d) of the Act. Because we collect the

information once, 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.

Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.

10.

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
Completion

Number of
Frequency
Respondents of
Response

Average
Burden
per
Response
(minutes)

Estimated
Total
Annual
Burden
(hours)

Average
Theoretical
Hourly
Cost
Amount
(dollars)*
18,597
$10.22*

Total Annual
Opportunity
Cost
(dollars)**

SSA-3441-BK
22,316
1
50
$190,061**
(Paper Form)
Electronic
337,702
1
50
281,418
$10.22* $2,876,092**
Disability
Collect System
(EDCS)
i3441
400,602
1
33
220,331
$10.22* $2,251,783**
(Internet Form)
Totals
760,620
520,346
$5,317,936**
* We based this figure on average DI payments, as reported in SSA’s disability
insurance payment data.
** This figure does not represent actual costs that SSA is imposing on recipients

of Social Security payments to complete this application; rather, these are
theoretical opportunity costs for the additional time respondents will spend to
complete the application. There is no actual charge to respondents to
complete the application.
The total burden for this ICR is 520,346 burden hours (reflecting SSA
management information data), which results in an associated theoretical (not
actual) opportunity cost financial burden of $5,317,936. SSA does not charge
respondents to complete our applications.
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 $8,129,306. This
estimate accounts for costs from the following areas: (1) designing, printing, and
distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS
staff) information collection and processing time; and (3) systems development,
updating, and maintenance costs.

15.

Program Changes or Adjustments to the Information Collection Request
When we last cleared this IC in 2017, the burden was 847,946 hours. However,
we are currently reporting a burden of 520,346 hours. This change stems from a
decrease in the number of responses from 1,526,105 to 760,620, as well as an
increase in the completion times from 45 to 50 minutes, and 28 to 33 minutes.
Although the number of responses changed, SSA did not take any actions to cause
this change.

16.

Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.

17.

Displaying the OMB Approval Expiration Date
For the paper Form SSA-3441-BK, SSA will not publish 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 the OMB approval date. Since SSA
does not periodically (e.g., on an annual basis), revise and reprint its public-use
forms, OMB granted this exemption so SSA would not have to destroy stocks of
otherwise useable forms with expired OMB approval dates, thereby avoiding
Government waste.
For the electronic versions of the form (EDCS-3441 and i3441), SSA is not
requesting an exception to the requirement to display the OMB approval
expiration date.

18.

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).

Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.

Supporting Statement for the SSA-3368
Disability Report-Adult
20 CFR 404.1512 and 416.912
OMB No. 0960-0579
A.

Justification
1.

Introduction/Authoring Laws and Regulations
Adult applicants for Social Security Administration (SSA) disability benefits must
provide medical, job history, and any other evidence required by SSA’s
Commissioner to prove that his or her impairment(s) is disabling. Since SSA
needs a vehicle to collect this evidence, we use the paper Form SSA-3368 and its
electronic versions, Electronic Disability Collect System (EDCS) 3368 and the
Internet i3368, for this purpose.
Sections 223(d)(5)(A) and 1631(e)(1) of the Social Security Act (Act) a provide
that an individual must furnish medical and other evidence to prove he or she is
disabled. Implementing the regulations in sections 20 CFR 404.1512 and 416.912
of the Code of Federal Regulations state an individual must inform us about or
submit all evidence known or relates to whether or not he or she is blind or
disabled, and if asked, inform us about medical sources, age, education and
training, work experience, daily activities efforts to work, and any other factors
showing how impairment(s) affects his or her ability to work. Sections 205(a)
and 1631(d)(1) of the Act give the Commissioner the authority to establish
regulations and procedures governing the type of evidence needed to evaluate an
alleged disability and methods of collecting this evidence.
We are including the Information Collection Requests (ICR) for 0960-0072 (SSA454; i454); 0960-0144 (SSA-3441; i3441); 0960-0579 (SSA-3368; i3368); 09600632 (SSA-3380-BK); and 0960-0681 (SSA-3373-BK), under one new OMB
Control Number, 0960-0813 for the purposes of obtaining OMB approval for the
revisions we are making to these forms as part of the Rulemaking process for the
Removing the Education Category - Inability to Communicate in English - from
the Disability Determination Process, RIN 0960-AH86. For technical purposes,
we need to keep the regulatory-related changes to these forms on a separate track
through the publication of the Final Rule stage, as we need to continue to use
these forms, and renew their current OMB approvals, while simultaneously
obtaining approval for the changes due to the revised rules under RIN
0960-AH86. To ensure we maintain OMB’s approval for the current versions of
the forms, we will maintain this separate OMB number for duration of the NPRM
and Final Rule changes to RIN 0960-AH86. The Final Rule published on
February 25, 2020 at 85 FR 10586. Upon OMB’s approval of this ICR, we will
update these forms under their separate OMB Control Numbers and will
discontinue the new OMB approval, 0960-0813, as we will no longer require it.

Description of Collection
State Disability Determination Services (DDS) use Form SSA-3368 and its
electronic versions to determine if an adult disability applicant’s impairment(s) is

severe and, if so, how the impairment(s) affects the applicant’s ability to work.
This determination dictates whether or not the DDS and SSA will find the
applicant disabled and entitled to SSI payments. The respondents are applicants
for Title II disability benefits or Title XVI SSI payments.
3.

Use of Information Technology to Collect the Information
In accordance with the agency’s Government Paperwork Elimination Act plan,
SSA created an Internet version of Form SSA-3368. Based on our data, we
estimate approximately 97 percent of respondents under this OMB number use
the electronic versions. SSA designed the electronic modalities to collect the
same information as the paper form, however it is formatted differently to include
certain enhancements (e.g., instructions and help screens) to guide the interviewer
or applicant through the application process.
•

Electronic Disability Collect System (EDCS) SSA-3368:
Applicants may call or go into the SSA Field Office to provide the
information the collection requires. In these cases, a claims representative
interviews the applicant and enters his or her answers directly into the
EDCS SSA-3368. Approximately 86 percent of respondents use this option.

•

Internet 3368 (i3368):
The i3368 is a fully electronic version of the paper form. Adult disability
applicants or their representatives may access, complete, and submit the
SSA-3368 electronically through this internet-based application. SSA
designed the i3368 to walk first-time users through this information
collection. It contains numerous help screens and explanations about why
we ask certain questions on the form. Approximately 11 percent of
respondents use this option.

We also provide applicants with “fillable” and printable PDF version of the form
on SSA’s website.
4.

Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it
precludes duplication. SSA does not use another collection instrument to obtain
similar data.

Minimizing Burden on Small Respondents
This collection does not significantly affect small businesses or other small
entities.

Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-3368, the public have no way to apply for disability
benefits. We would deprive individuals of the right to present evidence pertaining
to their claim. Because we collect the information on an as needed basis, 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.

Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.

10.

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
Completion

Number of
Frequency
Respondents of
Response

Average
Burden
per
Response
(minutes)

Estimated
Total
Annual
Burden
(hours)

Average
Theoretical
Hourly
Cost
Amount
(dollars)*
9,068
$10.22*

Total Annual
Opportunity
Cost
(dollars)**

SSA-3368
6,045
1
90
$92,675**
(Paper form)
Electronic
1,263,104
1
90 1,894,656
$10.22* $19,363,384**
Disability
Collection
System
(EDCS)
i3368
989,361
1
90 1,484,042
$10.22* $15,166,909**
(Internet)
Totals
2,258,510
3,387,766
$34,622,968**
* We based this figure on average DI payments, as reported in SSA’s disability
insurance payment data.

** This figure does not represent actual costs that SSA is imposing on recipients
of Social Security payments to complete this application; rather, these are
theoretical opportunity costs for the additional time respondents will spend to
complete the application. There is no actual charge to respondents to
complete the application.
The total burden for this ICR is 3,387,766 burden hours (reflecting SSA
management information data), which results in an associated theoretical (not
actual) opportunity cost financial burden of $34,622,968. SSA does not charge
respondents to complete our applications.
13.

Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden on the respondents.

14.

Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $72,249,272. This
estimate accounts for costs from the following areas: (1) designing, printing, and
distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS
staff) information collection and processing time; and (3) systems development,
updating, and maintenance costs.

15.

Program Changes or Adjustments to the Information Collection Request
When we last cleared this IC in 2018, the burden was 5,328,244 hours. However,
we are currently reporting a burden of 3,387,766 hours. This change stems from a
decrease in the number of responses from 3,552,162 to 2,258,510. 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.

16.

Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.

17.

Displaying the OMB Approval Expiration Date
For our paper Form SSA-3368, 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.
For our Internet i3368, SSA is not requesting an exception to the requirement to
display the OMB approval expiration date.

18.

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).

Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.

Supporting Statement for Form SSA-3380-BK
Function Report – Adult Third Party
20 CFR 404.1512, 404.1564, 416.912, and 416.964
OMB No. 0960-0635
A.

Justification
1.

Introduction/Authoring Laws and Regulations
Sections 205(a), 223(d)(5)(A), 1631(d)(1), and 1631(e)(1) of the Social Security
Act (the Act) require claimants for Social Security disability benefits to provide
medical and other evidence of their disability, with evidence requirements to be
established by the Commissioner of Social Security. These sections of the Act
also grant the Social Security Administration (SSA) the authority to establish
procedures for collecting and verifying this evidence. 20 CFR 404.1512 and
416.912 of the Code of Federal Regulations require claimants to provide the
following information: evidence of age; education and training; work experience;
daily activities; efforts to work; and any other evidence demonstrating how their
impairment affects their ability to work.
We are including the Information Collection Requests (ICR) for 0960-0072
(SSA-454; i454); 0960-0144 (SSA-3441; i3441); 0960-0579 (SSA-3368; i3368);
0960-0632 (SSA-3380-BK); and 0960-0681 (SSA-3373-BK), under one new
OMB Control Number, 0960-0813, for the purposes of obtaining OMB approval
for the revisions we are making to these forms as part of the Rulemaking process
for the Removing the Education Category - Inability to Communicate in English from the Disability Determination Process, RIN 0960-AH86. For technical
purposes, we need to keep the regulatory-related changes to these forms on a
separate track through the publication of the Final Rule stage, as we need to
continue to use these forms, and renew their current OMB approvals, while
simultaneously obtaining approval for the changes due to the revised rules under
RIN 0960-AH86. To ensure we maintain OMB’s approval for the current
versions of the forms, we will maintain this separate OMB number for duration of
the NPRM and Final Rule changes to RIN 0960-AH86. The Final Rule published
on February 25, 2020 at 85 FR 10586. Upon OMB’s approval of this ICR, we
will update these forms under their separate OMB Control Numbers and will
discontinue the new OMB approval, 0960-0813, as we will no longer require it.

Description of Collection
Individuals receiving or applying for Social Security Disability Insurance (SSDI)
or Supplemental Security Income (SSI) provide SSA with medical evidence and
other proof SSA requires to prove their disability. SSA, and Disability
Determination Services (DDS) on our behalf, collect this information using Form
SSA-3380-BK. We use the information to document how claimant’s disabilities
affect their ability to function, and to determine eligibility for SSI and SSDI
claims. The respondents are third parties familiar with the functional limitations
(or lack thereof) of claimants who apply for SSI and SSDI benefits. Respondents

include family members, neighbors, friends, etc., and past employers.
3.

Use of Information Technology to Collect the Information
Form SSA-3380 is available as a fillable PDF on SSA’s website, which the
respondent completes, prints, and mails to SSA. The DDS also mails the form to
the respondent to complete and mail back. SSA has not, yet, created an electronic
version of Form SSA-3380 under the agency’s Government Paperwork
Elimination Act (GPEA) plan due to competing priorities. We will revisit making
this form available electronically in the future, when our budget allows for it.

Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.

Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not collect this information, it would be impossible to determine
whether claimants are disabled, or beneficiaries are still disabled, and SSA would
not be able to discharge its mandate to pay benefits to those who are disabled.
Since the form is completed only once for an initial application, and on an
occasional basis if a beneficiary is selected for a continuing disability review or
appeals our decision, the information cannot be collected less frequently. There
are no technical or legal obstacles to burden reduction.

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.

Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.

10.

11.

Justification for Sensitive Questions
This information collection does not contain any questions of a sensitive nature.

12.

Estimates of Public Reporting Burden

Modality of
Completion

Number of
Frequency
Respondents of
Response

Average
Burden
per
Response
(minutes)

Estimated
Total
Annual
Burden
(hours)

Average
Total Annual
Theoretical Opportunity
Hourly
Cost
Cost
(dollars)**
Amount
(dollars)*
SSA-3380-BK
709,700
1
61
721,528
$22.50* $16,234,380**
* We based this figure on average U.S. citizen’s hourly salary, as reported by
Bureau of Labor Statistics data.
** This figure does not represent actual costs that SSA is imposing on recipients
of Social Security payments to complete this application; rather, these are
theoretical opportunity costs for the additional time respondents will spend to
complete the application. There is no actual charge to respondents to
complete the application.
The total burden for this ICR is 721,528 burden hours (reflecting SSA
management information data), which results in an associated theoretical (not
actual) opportunity cost financial burden of $16,234,380. SSA does not charge
respondents to complete our applications.
13.

Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden on the respondents.

14.

Annual Cost to Federal Government
The annual cost to the Federal Government is approximately $1,508,783. 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.

17.

OMB granted this exemption so SSA would not have to destroy stocks of
otherwise useable forms with expired OMB approval dates, avoiding Government
waste.
18.

Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements in 5 CFR
1320.9 and related provisions in 5 CFR 1320.8(b)(3).

Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.

Supporting Statement for Form SSA-3373-BK
Function Report – Adult
20 CFR 404.1512 and 20 CFR 416.912
OMB No. 0960-0681
A.

Justification
1.

Introduction/Authoring Laws and Regulations
Sections 205(a), 223(d)(5)(A), 1631(d)(1), and 1631(e)(1) of the Social Security
Act (Act) require individuals receiving or applying for Social Security disability
insurance (SSDI) or Supplemental Security Income (SSI) to provide medical and
other evidence of their disability. These sections of the Act grant the Social
Security Administration (SSA) the authority to establish procedures for collecting
and verifying this evidence. 20 CFR 404.1512 and 416.912 of the Code of
Federal Regulations provide detailed requirements of the types of evidence Social
Security disability claimants and beneficiaries must provide showing how their
impairment(s) affects their ability to work (e.g., evidence of age; education and
training; work experience; daily activities; efforts to work; and any other
evidence). SSA uses Form SSA-3373-BK, the Function Report-Adult, to collect
the information for adult disability cases.
We are including the Information Collection Requests (ICR) for 0960-0072
(SSA-454; i454); 0960-0144 (SSA-3441; i3441); 0960-0579 (SSA-3368; i3368);
0960-0632 (SSA-3380-BK); and 0960-0681 (SSA-3373-BK), under one new
OMB Control Number, 0960-0813, for the purposes of obtaining OMB approval
for the revisions we are making to these forms as part of the Rulemaking process
for the Removing the Education Category - Inability to Communicate in English from the Disability Determination Process, RIN 0960-AH86. For technical
purposes, we need to keep the regulatory-related changes to these forms on a
separate track through the publication of the Final Rule stage, as we need to
continue to use these forms, and renew their current OMB approvals, while
simultaneously obtaining approval for the changes due to the revised rules under
RIN 0960-AH86. To ensure we maintain OMB’s approval for the current
versions of the forms, we will maintain this separate OMB number for duration of
the NPRM and Final Rule changes to RIN 0960-AH86. The Final Rule published
on February 25, 2020 at 85 FR 10586. Upon OMB’s approval of this ICR, we
will update these forms under their separate OMB Control Numbers and will
discontinue the new OMB approval, 0960-0813, as we will no longer require it.

Description of Collection
SSA staff, and, on our behalf, State Disability Determination Services’ (DDS)
employees, collect the information via paper Form SSA-3373-BK, or through an
in-person or telephone interview for cases where we need information about a
claimant’s activities and abilities to evaluate the claimant’s disability. We use the
information to document how claimants’ disabilities affect their ability to
function, and to determine eligibility, or continued eligibility, for SSI and SSDI

claims. The respondents are Title II and Title XVI applicants (or current
recipients undergoing redeterminations) for disability payments.
3.

Use of Information Technology to Collect the Information
This form is available as a fillable PDF on SSA’s website, which the respondent
completes, prints, and mails to the DDS or brings to an SSA field office. SSA has
not yet created an electronic version of Form SSA-3373 under the agency’s
Government Paperwork Elimination Act (GPEA) plan due to competing
priorities. DDS offices, operating on several variations of five different legacy
computer systems, each programmed to support state-designed business
processes, conduct 99 percent of these collections. Before SSA can deploy an
electronic version of the SSA-3373, the agency must upgrade and standardize the
DDS case processing systems. We are currently working on a way to update the
DDS case processing systems.

Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.

Consequence of Not Collecting Information or Collecting it Less Frequently
If SSA did not collect this information, we would be unable to determine a
claimant’s disability, or the extent of continuing disability; and we would be
unable to fulfill our mandate to make payments to those who are disabled. Since
respondents complete the form only once for an initial application, or on an
occasional basis if selected for a continuing disability review or for an appeal of
our decision, we cannot collect the information less frequently. There are no
technical or legal obstacles to burden reduction.

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.

Payment or Gifts to Respondents
SSA provides no payment or gifts to the respondents, except for the actual
disability payments (if one qualifies for them).

10.

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
Completion

Number of
Frequency
Respondents of
Response

Average
Burden
per
Response
(minutes)

Estimated
Total
Annual
Burden
(hours)

Average
Total Annual
Theoretical Opportunity
Hourly
Cost
Cost
(dollars)**
Amount
(dollars)*
SSA-3373-BK
1,734,635
1
61 1,763,546
$10.22* $18,023,440**
* We based this figure on average DI payments, as reported in SSA’s disability
insurance payment data.
** This figure does not represent actual costs that SSA is imposing on recipients
of Social Security payments to complete this application; rather, these are
theoretical opportunity costs for the additional time respondents will spend to
complete the application. There is no actual charge to respondents to
complete the application.
The total burden for this ICR is 1,763,546 burden hours (reflecting SSA
management information data), which results in an associated theoretical (not
actual) opportunity cost financial burden of $18,023,440. SSA does not charge
respondents to complete our applications.
13.

Annual Cost to the Respondents (Other)
This collection does not cause a known cost burden on the respondents.

14.

Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $3,403,000. 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.

17.

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.

18.

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).

Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.

File Type	application/pdf
Author	SDunigan
File Modified	2020-02-25
File Created	2020-02-25