Disability Case Development Information Collections

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Muscle Examination	Form	Modified	Repair queued
Form Pain Questionnaire Pain Questionnaire	Form	Modified	Available
Form Pain Questionnaire Category III - Pain/Other Symptoms/Impairment Information	Form	Modified	Available
Sample CE Forms	Form and Instruction	Modified	Repair queued
Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms")	Form and Instruction	Modified	Repair queued
Addendum - 0555.docx	Supplementary Document	Uploaded 2020-12-04	Available
Supporting Statement - 0555.docx	Supporting Statement A	Uploaded 2020-12-09	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9480	Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)	Other-Samples of DDS CE Forms	Modified
241087	Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category)	Other-Telehealth Consultative Examination Agreement From	Modified
181780	Category III - Pain/Other Symptoms/Impairment Information	Form	Modified	Muscle Examination
181780	Category III - Pain/Other Symptoms/Impairment Information	Form	Modified	Pain Questionnaire
181780	Category III - Pain/Other Symptoms/Impairment Information	Form	Modified
181780	Category III - Pain/Other Symptoms/Impairment Information	Other-CE- Arterial Doopler Evaluation With Toe	Modified
179046	Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms")	Form and Instruction	Modified	Sample CE Forms
179046	Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms")	Form and Instruction	Modified
179022	Category II - MER, ERE & Connect Direct transmission of MER forms (subset of "MER Samples" category)	Other-ERE Transmission of "MER Samples" Category	Modified
179020	Category II - MER Paper Submissions (subset of "MER Samples") category	Other-Sample of MER forms	Modified
179019	Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)	Other-Sample of state DDS Claimant Report Letter/Form	Modified
179018	Category I, CE b) Claimant/Appointment Letter Information (subset of "CE Forms Samples" category)	Other-Sample of Appointment Letter Included	Modified
179017	Category I, CE a) Medical Evidence from CE Providers (Electronic Transmission through ERE; subset of "CE Forms Samples" category)	Other-Sample of types of information sent through ERE; electroni	Modified

ICR Details

OMB Control No: 0960-0555	ICR Reference No: 202008-0960-021
Status: Historical Active	Previous ICR Reference No: 202008-0960-015
Agency/Subagency: SSA	Agency Tracking No:
Title: Disability Case Development Information Collections
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: 04/13/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/09/2020
Terms of Clearance: The agency substantially modified the instruments and supporting statement associated with this collection to reflect the adoption of Disability Case Processing System DCPS2 system and the resultant standardization of CE notices and forms. Prior to triannual reapproval, the agency will offer to OMB a briefing on any outstanding non-standardized (i.e. DDS generated) forms or notices associated with this information collection.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2026	36 Months From Approved	04/30/2023
Responses	17,740,000	0	17,740,000
Time Burden (Hours)	4,501,999	0	4,501,999
Cost Burden (Dollars)	0	0	0

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Abstract: State disability determinations services collect the information SSA needs to administer our disability program. For the purposes of this ICR, we divide this information into three categories: 1) consultative examinations (a/b/c); 2) medical evidence of record; and 3) pain/other symptoms/impairment. Respondents are individuals, private sector, and State and local governments.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 421 Name of Law: Social Security Act
   US Code: 42 USC 1382c Name of Law: Social Security Act
   US Code: 42 USC 405 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:
	85 FR 63630	10/08/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 79064	12/08/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)
Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms")	N/A	Sample CE Forms
Category I, CE a) Medical Evidence from CE Providers (Electronic Transmission through ERE; subset of "CE Forms Samples" category)
Category I, CE b) Claimant/Appointment Letter Information (subset of "CE Forms Samples" category)
Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)
Category I, CE d) One-Time CE Claimant Telehealth Call Script (subset of "CE Forms Samples" category)
Category II - MER Paper Submissions (subset of "MER Samples") category
Category II - MER, ERE & Connect Direct transmission of MER forms (subset of "MER Samples" category)
Category III - Pain/Other Symptoms/Impairment Information	Pain Questionnaire, N/A	Pain Questionnaire ,   Muscle Examination

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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	17,740,000	17,740,000	0	0	0	0
Annual Time Burden (Hours)	4,501,999	4,501,999	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:

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Annual Cost to Federal Government: $574,000,000

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? 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: 12/09/2020

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