Certification of Low Birth Weight for SSI Eligibility

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-3830 Certification of Low Birth Weight for SSI Eligibility	Form	Modified	Available
Form SSA-3830 Certification of Low Birth Weight for SSI Eligibility	Form	Modified	Repair queued
Addendum - 0720.docx	Supplementary Document	Uploaded 2021-01-28	Available
Addendum - 0720.docx	Supplementary Document	Uploaded 2021-01-28	Missing upstream
Supporting Statement - 0720 (Final).docx	Supporting Statement A	Uploaded 2023-06-13	Available
Supporting Statement - 0720.docx	Supporting Statement A	Uploaded 2021-01-28	Missing upstream

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9777	Certification of Low Birth Weight for SSI Eligibility	Form	Modified	Certification of Low Birth Weight for SSI Eligibility
9777	Certification of Low Birth Weight for SSI Eligibility	Form	Modified

ICR Details

OMB Control No: 0960-0720	ICR Reference No: 202010-0960-007
Status: Active	Previous ICR Reference No: 201709-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Certification of Low Birth Weight for SSI Eligibility
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: 06/14/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/28/2021
Terms of Clearance: The agency made minor clarifications to the supporting statement to improve its description.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2026	36 Months From Approved	06/30/2023
Responses	28,125	0	28,125
Time Burden (Hours)	7,031	0	7,031
Cost Burden (Dollars)	0	0	0

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Abstract: Hospitals and claimants use Form SSA-3830 to provide medical information to local field offices (FOs) and Disability Determinations Services (DDSs) on behalf of infants with low birth weight. FOs use the form as a protective filing statement, and the medical information to make presumptive disability findings, which allow expedited payment to eligible claimants. DDSs use the medical information from the SSA-3830 to determine disability and continuing disability. The respondents are hospitals and claimants who have information identifying low birth weight babies and their medical conditions.

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Authorizing Statute(s): US Code: 42 USC 1383b Name of Law: Social Security Act
   US Code: 42 USC 1382c 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 76142	11/27/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 7446	01/28/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Certification of Low Birth Weight for SSI Eligibility	SSA-3830	Certification of Low Birth Weight for SSI Eligibility

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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	28,125	28,125	0	0	0	0
Annual Time Burden (Hours)	7,031	7,031	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: $212,055

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: 01/28/2021

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