Questionnaire for Children Claiming SSI Benefits

Forms and Documents

Document	Type	Status	Availability
Form SSA-3881 BK Questionnaire for Children Claiming SSI Benefits	Form	Modified	Available
Supporting Statement - 0499 (Final).docx	Supporting Statement A	Uploaded 2021-12-23	Available
Supporting Statement - 0499.docx	Supporting Statement A	Uploaded 2020-09-08	Repair queued
Addendum - 0499 (Final).docx	Supplementary Document	Uploaded 2021-12-23	Available
Addendum - 0499.docx	Supplementary Document	Uploaded 2020-09-08	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
9392	Questionnaire for Children Claiming SSI Benefits - Paper Version	Form	Modified	Questionnaire for Children Claiming SSI Benefits
9392	Questionnaire for Children Claiming SSI Benefits - Paper Version	Other-Revised PRA Statement	Modified
250963	Questionnaire for Children Claiming SSI Benefits - Intranet Version	Other-EDCS Screens	New

ICR Details

OMB Control No: 0960-0499	ICR Reference No: 202005-0960-005
Status: Active	Previous ICR Reference No: 201701-0960-013
Agency/Subagency: SSA	Agency Tracking No:
Title: Questionnaire for Children Claiming SSI Benefits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/28/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/08/2020
Terms of Clearance: The agency provided additional description of the information collection, adjusted the burden, and clarified electronic submission capability.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2024	36 Months From Approved	12/31/2021
Responses	125,000	0	130,000
Time Burden (Hours)	103,125	0	65,000
Cost Burden (Dollars)	0	0	0

---

Abstract: Parents or legal guardians seeking to obtain or retain SSI eligibility for their children use Form SSA-3881-BK to provide SSA with the addresses of non medical sources such as schools, counselors, agencies, organizations, or therapists who have information about a child’s function. The adjudicative team (a disability examiner and a medical or psychological consultant) of the State disability determination services (DDS) office collects the information to help determine a child’s claim or continuing eligibility for SSI. The respondents are the parents, guardians, and other caretakers of applicants who appeal SSI childhood disability decisions, or of recipients undergoing a continuing disability review.

---

Authorizing Statute(s): US Code: 42 USC 1383 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:
	85 FR 37996	06/24/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 53428	08/28/2020
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Questionnaire for Children Claiming SSI Benefits - Intranet Version
Questionnaire for Children Claiming SSI Benefits - Paper Version	SSA-3881 BK	Questionnaire for Children Claiming SSI Benefits

---

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	125,000	130,000	0	0	-5,000	0
Annual Time Burden (Hours)	103,125	65,000	0	0	38,125	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 2017, the burden was 65,000 hours. However, we are currently reporting a burden of 62,500 hours. This change stems a decrease in the number of responses from 130,000 to 125,000. 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. These figures represent current Management Information data.

---

Annual Cost to Federal Government: $1,566,195

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

---

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: 09/08/2020

---