Supporting Statement - 0540 (Final)

Supporting Statement for Form SSA-3371-BK

Pain Report-Child

20 CFR 416.912, 404.512

OMB No. 0960-0540

A. Justification

1. Introduction/Authoring Laws and Regulations

Sections 1614 (a)(3)(H)(i) and 1631(e)(1) of the Social Security Act (Act) require claimants for SSA benefits to furnish medical and other evidence of disability as required to prove their disability. Disability regulations in 20 CFR 416.912 and 404.512 require individuals to provide medical evidence and, if asked, evidence of age; education; training; work experience; daily activities; efforts to work; and any other evidence showing how their impairment(s) affects the ability to work or, in the case of a child, how the claimant functions. Section 1631(d)(1) of the Act provides the Commissioner of the Social Security Administration (SSA) with the full power and authority to make rules and regulations, establish procedures, and to adopt reasonable and proper rules for the nature and extent of the evidence as well as the methods of taking and furnishing the same to evaluate the alleged disability.

2. Description of Collection

Before SSA can make a disability determination for a child, we require evidence from Supplemental Security Income (SSI) applicants or claimants to prove their disability. Form SSA-3371-BK provides disability interviewers, and SSI applicants or claimants in self-help situations, with a convenient way to record information regarding the claimant’s pain and medications. The State disability determination services adjudicators and administrative law judges then use the information from Form SSA-3371-BK to assess the effects of pain on function for purposes of determining disability under the Act. The respondents are applicants for, or claimants of, SSI.

3. Use of Information Technology to Collect the Information

Form SSA-3371-BK is available on SSA’s website for respondents to print and mail back to SSA, or complete in a field office. This collection does not currently have a fully public-facing Internet version, as we prioritized other information collections for full electronic conversions. We will ultimately convert most existing ICRs to full electronic versions depending on how they fall within the overall prioritization and project roadmap once funding is secured, but this may be unconnected to the PRA approval lifecycle. In the interim, we evaluated this collection for conversion to a submittable PDF and it is included in a list for future prioritization. Once we have the submittable PDF ready for implementation, we will submit a Change Request to OMB for prior approval.

3. 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.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently

If we did not use Form SSA-3371-BK, non-standardized requests for information on pain would vary and result in less efficiency, reliability, and quality assurance among childhood SSI disability reviews. Because we collect the information as needed, 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.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on November 30, 2021, at 86 FR 68034, and we received no public comments. The 30-day FRN published on February 7, 2022 at 87 FR 6929. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the maintenance of this form.

9. 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 Collection	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollars)*	Average Wait Time in Field Office (minutes)**	Total Annual Opportunity Cost (dollars)***
SSA-3371	1,500	1	15	375	$10.95*	24**	$10,676***

*We based this figure by the average DI payments based on SSA's current FY 2021 data (https://www.ssa.gov/legislation/2021FactSheet.pdf),

** We based this figure on the average FY 2022 wait times for field offices, based on SSA’s current management information 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 time burden for this collection. OIRA based their estimation on a spatial analysis of SSA’s current field office locations and the location of the average population centers based on census tract information, which likely represents a 13.97-mile driving distance for one-way travel. We depict this on the chart below:

Total Number of Respondents Who Visit a Field Office	Frequency of Response	Average One-Way Travel Time to a Field Office (minutes)	Estimated Total Travel Time to a Field Office (hours)	Total Annual Opportunity Cost (dollars)****
1,500	1	30	750	$15,128****

****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

Per OIRA, we include this travel time burden estimate under the

5 CFR 1320.8(a)(4), which requires us to provide “time, effort, or financial resources expended by persons [for]…transmitting, or otherwise disclosing the information,” as well as 5 CFR 1320.8(b)(3)(iii) which requires us to estimate “the average burden collection…to the extent practicable.” SSA notes that we do not obtain or maintain any data on travel times to a field office, nor do we have any data that shows that the average respondent drives to a field office, rather than using any other mode of transport. SSA also acknowledges that respondents’ mode of travel and, therefore, travel times vary widely dependent on region, mode of travel, and actual proximity to a field office.

NOTE: We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates in the paragraph below.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection. Per our management information data, we believe that

15 minutes accurately shows the average burden per response for reading the instructions, gathering the facts, and answering the questions. Based on our current management information data, the current burden information we provided is accurate. The total burden for this ICR is 1,500 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $25,804. 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 $86,520. This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars*
Designing and Printing the Form	Design Cost + Printing Cost	$300*
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$0*
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$82,800*
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0*
Systems Development, Updating, and Maintenance	GS-9 employee x man hours for development, updating, maintenance	$3,420*
Quantifiable IT Costs	Any additional IT costs	0*
Total		$86,520

* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have.  First, since we work with almost every US citizen, we often do bulk mailings, and cannot track the cost for a single mailing.  In addition, it is difficult for us to break down the cost for processing a single form, as field office and State Disability Determination Services staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent.  As well, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection Request

When we last cleared this IC in 2019, the burden was 62,500 hours. However, we are currently reporting a burden of 1500 hours. This change stems a decrease in the number of responses from 250,000 to 1,500. This decrease stems from a decrease in the number of respondents completing Form SSA-3371. 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.

* Note:  The total burden reflected in ROCIS is 1,725, while the burden cited in #12 above is 375. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a

30-minute, one-way, drive burden. In contrast, the chart in #12 above reflects actual burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

16. 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.

16. 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).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

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