Function Report - Adult Third Party

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-3380 Function Report -- Adult Third Party	Form and Instruction	Modified	Repair queued
Form SSA-3380 Function Report - Adult Third Party	Form and Instruction	Modified	Repair queued
Addendum 0635.docx	Supplementary Document	Uploaded 2021-10-05	Repair queued
Supporting Statement - 0635 (Final).docx	Supporting Statement A	Uploaded 2021-11-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9663	Function Report - Adult Third Party	Form and Instruction	Modified	Function Report -- Adult Third Party
9663	Function Report - Adult Third Party	Form and Instruction	Modified
9663	Function Report - Adult Third Party	Other-Privacy Act Statement Revised	Modified

ICR Details

OMB Control No: 0960-0635	ICR Reference No: 202110-0960-003
Status: Active	Previous ICR Reference No: 201805-0960-013
Agency/Subagency: SSA	Agency Tracking No:
Title: Function Report - Adult Third Party
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: 09/29/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/01/2021
Terms of Clearance: The agency made clarifying changes to the description of the information collection, minor modifications to instructions on the form, and updated the burden estimate. Prior to resubmission to OMB, the agency is encouraged to add additional instructions under questions 9, 15, 16, 17 to remind respondents to include discussion of activities where the claimant may require help from others in completing the relevant activity. If the agency declines to include additional instruction for these questions, it will schedule a meeting with OMB to discuss its decision prior to publishing the 60-day Federal Register notice.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2026	36 Months From Approved	09/30/2023
Responses	709,700	0	709,700
Time Burden (Hours)	721,528	0	721,528
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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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
   US Code: 42 USC 405 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:
	86 FR 46897	08/20/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 59262	10/26/2021
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
Function Report - Adult Third Party	SSA-3380	Function Report -- Adult Third Party

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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	709,700	709,700	0	0	0	0
Annual Time Burden (Hours)	721,528	721,528	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: $1,536,687

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: 11/01/2021

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