OMB No. 0960-NEW
Revisions to the Information Collections:
Note: SSA does not have the revised screens available for review at the publication of the NPRM stage; however, the screens will mirror the changes on the revised forms. The following shows the revisions for each information collection mentioned in this rule.
Revisions to the HA-4633 (0960-0300):
Change #1: We are only collecting data for jobs in last 5 years instead of 15 years. This change will lower the expected burden time to 20 minutes to complete the form.
Justification #1: The change is required because we are redefining the relevant period we use to determine whether work qualifies as past relevant work for initial claims.
Revisions to the SSA-3368 (0960-0579):
Change #1: We are updating the instructions as follows:
We are adding a statement about completing the report online.
We are moving our definition of disability from page 2 to page 1.
We are adding the SSA-800 number.
We are adding instructions for what is needed to complete the report.
We are adding instructions for how to submit the report.
Justification #1: We are reorganizing information and adding the contact information to improve customer service and for consistency with other forms.
Change #2: We are revising information about the disabled person in Section 1, as follows:
We are revising the title of the section to information about you.
We are revising the sentence about when we use “you,” “your,” or “person with a disability” we mean the person applying for disability benefits.
We are replacing pronouns which refer to the person with a disability as “him” or “her” with “them.”
We are revising the sentence to include other names the person with a disability may have used in medical or educational records and we are moving this statement from 1.J, to 1.C.
We are adding a statement about providing a phone number where we can leave a message in 1.F. We are also combining our request for a primary and secondary phone number in 1.F.
Justification #2: We are changing the pronouns we use to non-gendered pronouns to align with President Biden’s Executive Order (EO) 13988, Preventing and Combating Discrimination on the Basis of Gender Identify and Sexual Orientation. We are updating and reordering the questions to improve accuracy, usability, and for consistency with other forms.
Change #3: We are revising contacts in Section 2 as follows:
We are revising the introduction to “is there someone we can contact who can help with your claim, if needed,” including examples, and adding check boxes for “yes” or “no.”
For “yes,” we are adding text about providing two contact persons other than a doctor who knows about your claim and can help us reach you.
For “no,” we are adding text that recommends providing us with at least one contact person.
We are replacing “you” with “Person in 1.A.” in 2.B.
We are moving the questions about who is completing the form in 2.F. through 2.J. to the end of the form after the signature.
We are adding an additional contact to 2.F. through 2.J. requesting the same information as 2.A. through 2.E.
Justification #3: We are adding this information to conform to the revised failure to cooperate policy and to improve accuracy and usability.
Change #4: We are making the following revisions to Section #3:
We are changing the title of section from medical conditions to medical information, and we are changing the question about medical conditions in 3.A.
We are removing “without shoes” from 3.B. and 3.C.
We are removing the question about pain and other symptoms in 3.D.
Justification #4: We are updating the section to improve accuracy, usability, and for consistency with other forms.
Change #5: We are revising work activity in Section #4 as follows:
We are changing the date format to MM/DD/YYYY in 4.B., 4.C., 4.D., and 4.F.
We are adding “or your employer” and revising the sentences “for example” to “examples include” and “when did the changes start” in 4.D. and 4.F.
We are updating the SGA amount and replacing “gross” with “before tax” in 4.E. and 4.G.
Justification #5: We are revising the date format, updating the SGA threshold, revising statements and examples, and adding before tax to improve accuracy and usability.
Change #6: We are revising education and training in Section #5, as follows:
We are adding “literacy” to the section title.
We are changing the wording in 5.A. to:
Use the word “select” instead of “check” the highest level of school completed.
Add a statement “including homeschooling, online education, and education received in a foreign country.”
Revise the statement “select 12 if you completed a graduate equivalency degree (GED) and we removed the text “GED” and the check box.
We are changing the wording of the questions in 5.B. to say:
“Were you in special education”
“If yes, select the last grade you were in special education,”
“Reason(s) for special education,” and
“The school where you were last in special education.”
We are changing the wording in 5.C. to:
“Have you received any type of training (specialized job, trade, or vocational),”
Add text to the no box “go to 5.E.” and to the yes box “complete the table below,” and
Ask for the name and location of a training facility, type of program, and change the date format to MM/YYYY.
We are adding “READING” in 5.E. and WRITING in 5.F.
Justification #6: We are making these changes to improve accuracy, usability, and for consistency with other forms.
Change #7: We are revising “job history” to “work history” in the title of Section #6.
We are making the following changes in 6.A.:
We are changing the wording to “did you have a job in the last 5 years” with options for yes and no.
We are replacing “up to 5 jobs” with “all” jobs and “15” with “5” years.
We are removing “before you became unable to work because of your physical or mental conditions.”
We are moving “list your most recent job first” to a list of bullets and we are adding bullets “include self-employment” and to “include work in a foreign country.”
We are changing the date format to MM/YYYY and clarifying the frequency of pay in the work history table.
We are revising the questions about how many jobs you had.
Justification #7: We are making this change to conform to the revised regulation for how we consider the period of time when determining whether an individual’s past work is relevant for purposes of disability determinations and decisions at step four of the sequential evaluation process. We are also making changes to improve accuracy, usability, and for consistency with other forms.
Change #8: We are making the following additional changes to work history in 6.B.:
We are changing the wording of the heading to “information about your work.”
We are changing the wording of the question “describe this job” and “what did you do all day” to “for the job you listed in 6.A., describe in detail the tasks you did in a typical workday” and adding examples.
We are moving the statement “if you need more space, write in the remarks section” to the top of the page for all the work history sections.
Justification #8: We are making this change to conform to the revised regulation for how we consider the period of time when determining whether an individual’s past work is relevant for purposes of disability determinations and decisions at step four of the sequential evaluation process. We are changing the format and order of the questions to improve accuracy, usability and for consistency with other forms.
Change #9: We are making the following additional changes to work history in 6.C.:
We are changing the questions for use of technical knowledge and skills, writing, completing reports, or performing any duties like this and the check boxes to a narrative format, and
We are moving these questions to 6.B.
Justification #9: We are making this change to collect relevant vocational information for purposes of disability determinations and decisions at step four of the sequential evaluation process. We are changing the format and order of the questions to improve accuracy, usability, and for consistency with other forms.
Change #10: We are making the following additional changes to work history in 6.D.:
We are moving the work activity table from 6.D. to 6.C.
We are changing the heading to “physical and environmental requirements of your work” and revising the question before the activity table to an introductory statement and we are including additional clarification and examples to complete the activity table
We are making the following changes to the activity table:
Adding a statement “the total hours/minutes for the activity should correspond with the total number of hours in a typical workday.”
Combining “standing and/or walking” into one question in the activity table.
Changing the wording of the question for using fingers and hands, adding examples, and adding boxes for one or both hands in the activity table.
Separating reaching into two questions for “reaching at/or below the shoulder” and “reaching overhead (above the shoulder)” and adding boxes for one arm or both arms in the activity table.
Separating climbing into two questions for climbing stairs or ramps and climbing ladders, ropes, or scaffolds in the activity table.
Adding a column with an example in the activity table.
We are adding text “if you need more space, use Section 11” after the activity table.
We are adding a question “did the job expose you to any of the following with check boxes for outdoors, extreme heat (non-weather related), extreme cold (non-weather related), wetness, humidity, hazardous substances, moving mechanical parts, high exposed places, heavy vibration, loud noise, and other.”
Justification #10: We are making this change to conform to the revised regulation for how we consider the period of time when determining whether an individual’s past work is relevant for purposes of disability determinations and decisions at step four of the sequential evaluation process. We are changing the format and order of the questions to improve accuracy, usability, and for consistency with other forms.
Change #11: We are the following additional changes to work history in 6.E through 6.G.:
We are changing the wording of lifting and carrying you did in your job in 6.E. to “tell us about lifting and carrying in this job” and moving this question after the activity table in 6.C.
We are changing the wording of “select the heaviest weight lifted” and “select the weight frequently lifted” in 6.F. and 6.G. and including check boxes and examples. We are adding a check box for “less than 1 lb.” to these questions about how much you lifted. We are moving these questions after the activity table in 6.C.
Justification #11: We are making this change to collect relevant vocational information for purposes of disability determinations and decisions at step four of the sequential evaluation process. We are changing the format and order of the questions to improve accuracy, usability, and for consistency with other forms.
Change #12: We are making the following additional changes to work history in 6.H and 6.I.:
We are changing the questions for how many people did you supervise, did you hire and fire, and were you a lead worker with check boxes to narrative question about supervising others, supervisory duties, and we are including examples. We are also moving the revised question to 6.B.
Justification #12: We are making this change to collect relevant vocational information for purposes of disability determinations and decisions at step four of the sequential evaluation process. We are changing the format and order of the questions to improve accuracy, usability, and for consistency with other forms. We are removing questions related to obsolete policy.
Change #13: We are changing the wording to “are you currently taking any prescription or non-prescription medicine(s)” in Section #7. We are also changing the wording of “reason for medicine” to include “if known” in the table.
Justification #13: We are asking for only current medications to capture evidence used to establish impairment severity and improve accuracy, usability, and consistency with other forms.
Change #14: We are making the following changes in Section #8:
Changing the wording of the introductory text from “doctors or other health care professionals” to “health care providers” and adding examples and we are moving this question to 8.A.
Removing questions that ask whether you were treated for physical or mental conditions and the check boxes in 8.A. and 8.B. and the statement about “if you answered no to both 8.A. and 8.B.”
Instructing respondents to “complete the chart(s) below.”
Adding text “you may find this information on medical bills, online medical chart, or the internet.”
Justification #14: We are making these changes to improve accuracy, usability, and for consistency with other forms.
Change #15: We are making the following additional changes to the medical treatment tables in Section #8.
Removing the introductory text about who may have medical records and about your next appointment in 8.C..
Moving the medical treatment tables in 8.C. through 8.G. to 8.A.i-iv.
Adding the text “name of facility or office” and “name of the health care provider that treated you,”
Removing the patient ID# field,
Removing medical sources of treatment from the dates of treatment (e.g. clinic, emergency room, overnight hospital stays) since we ask for this information in the revised treatment table,
Revising the dates the respondent was seen to “first seen,” “last seen,” and “next seen,” and adding “if known,”
Changing the date format to MM/YYYY,
Removing the question about what treatment you received,
Removing the question about tests the provider performed or sent you to, or scheduled you to take, and the check boxes and moving the test table to 8.B.
Justification #15: We are making these changes to improve accuracy, usability, and for consistency with other forms.
Change #16: We are making the following additional changes to the test tables in Section #8.
Removing the test table from the medical treatment table (discussed in Change 14) and moving the table to 8.B.
Changing the wording about tests the provider performed to “did any of the providers listed in 8.A. order any medical tests for you” and “include tests already performed and scheduled in the future” with check boxes.
Adding Psychological/IQ test to the table:
Adding a “name of health care provider” column,
Changing the date of test to MM/YYYY.
Justification #16: We are making the changes to improve accuracy, usability, and for consistency with other forms.
Change #17: We are adding “other than your medical providers” in Section #9 and we are including examples. We are changing text for the "No” check box to “go to Section #10.”
Justification #17: We are making the changes to improve accuracy, usability, and for consistency with other forms.
Change #18: We are making the following changes in Section #10:
Removing the statement about completing section #10 only if you are already receiving SSI and “vocational rehabilitation and employment” from the title of section #10.
Adding introductory text about providing support services and moving the bulleted examples in 10.A. to the introductory text.
Changing the text in 10.A. include other support services that helped you go to work.
Changing the wording to “facility or organization name” in the support services table in 10.B.
Combining the questions in 10.C. and 10.D. and including check boxes with “date began,” expected completion date” and “date stopped” fields in 10.C.
Changing the question about listing services from a narrative form to check boxes for each test or service in 10.E and moving the question to 10.D.
Justification #18: We are making the changes to improve accuracy, usability, and for consistency with other forms.
Change #19: We are changing the question from listing types of services, tests, or evaluations in 10.E to check boxes and moving the question to 10.D.
Justification #19: We are making the changes to improve accuracy, usability, and for consistency with other forms.
Change #20: We are revising the end of the form as follows:
We are revising the title of section #12 to “who is completing this report.”
We are reformatting the date to MM/DD/YYYY.
We are adding the question about the person completing the form in 2.A. and in 2.F..
We are revising the check box options to include the person listed in 1.A, the person listed in 2.A, the person listed in 2.F, or someone else and we are adding a table to provide this information.
Justification #20: We are adding this information to conform to the revised failure to cooperate policy and improve accuracy, usability, and consistency with other forms.
Revisions to the SSA-3369 (0960-0578):
Change #1: We are updating the instructions on page #1 as follows:
We clarified that the office that makes the disability decision on your case will use the information you provide in this report to understand how your illnesses, injuries, or conditions might affect your ability to do work for which you are qualified and moved this paragraph to the beginning.
We added a statement, “if you cannot speak or understand English, we will provide an interpreter free of charge.”
We updated the heading to “what you need to complete this report” and added “information about all the jobs that you have had in the last 5 years” to the bulleted list below.
We added a statement, “if you cannot remember all the information about your jobs, provide what you do remember” in the bulleted list.
Justification #1: We updated this language to improve customer service, usability, and accuracy, for consistency with the revised SSA-454, and to reflect the proposed 5-year relevant work period.
Change #2: We are updating Section #1 as follows:
We added a penalty of perjury statement.
We revised the sentence about when we use “you,” “your,” or “person with a disability,” we mean the person applying for disability benefits.
We revised the title of the section to “information about you.”
We replaced pronouns which refer to the person as “him” or “her” with “them.”
We added a request for a secondary phone number, if available.
Justification #2: We changed the pronouns to gender-neutral pronouns to align with President Biden’s Executive Order (EO) 13988, Preventing and Combating Discrimination on the Basis of Gender Identify and Sexual Orientation. We also updated the language for clarity, and consistency with the revised SSA-454.
Change #3: We are updating Section #2 as follows:
We replaced “15” with “the last 5 years.”
We removed “before you became unable to work because of your illnesses, injuries, or conditions.”
We added bullets for “include self-employment” and “work in a foreign country.”
We changed the date format to MM/YYYY for work to and from in the work column.
Justification #3: We made these changes to conform to the revised regulations for how we consider the period of time when we determine whether a person’s past work is relevant for purposes of disability determinations and decisions at steps four and five of the sequential evaluation process. We also revised the table to improve consistency and usability.
Change #4: We are revising the questions for work information for job numbers 1-6 as follows: We revised and moved the statement, “if you need more space, use Section 3 - Remarks” to the top of the page for each job.
Justification #4: We made these change to improve accuracy and usability.
Change #5: We are updating the questions on “information about your work” as follows:
We changed the wording of question to “for the job you listed in Job Title No, 1-5, describe in detail the tasks you did in a typical workday” and added examples.
We changed the question for machines, tools, and equipment from a check box to a narrative, “list the machines, tools, and equipment you used regularly when doing this job and explain what you used them for” and added examples.
We changed the questions for how many people did you supervise, did you hire and fire, and were you a lead worker from a check box to a narrative, “If any of the tasks listed above involved supervising others, describe who or what you supervised and what supervisory duties you had” and added examples.
We changed the question for use of technical knowledge and skills, from a check box to a narrative, “tell us about the work-related skills you used in this job and the job duties you completed using these skills” and added examples.
We changed the question for writing, completing reports, or performing any duties like this from a check box to a narrative, “if any of the tasks listed above involved writing or completing reports, describe the type of report you wrote or completed and how much time you spent on it per workday or workweek.”
We added a question “did your job require you to interact with coworkers, the general public, or anyone else” with options for yes and no, and “if yes, describe who you interacted with, the purpose of the interaction, how you interacted, and how much time you spent doing it workday or workweek,” and added examples.
Justification #5: We made these changes to conform to the revised regulations for how we consider the period of time when we determine whether a person’s past work is relevant for purposes of disability determinations and decisions at steps four and five of the sequential evaluation process. We also revised questions and added examples to improve accuracy and usability.
Change #6: We are updating the questions on “physical and environmental requirements of work” as follows:
We changed the wording of the question before the activity table to “tell us how much time you spent doing the following physical activities in a typical workday.”
We are adding a statement “the total hours/minutes for standing and/or walking and sitting should equal the hours per day.”
We added a column with an example in the activity table for Job No. 1 and added a statement above, “the example below shows an 8-hour workday with 2 hours standing and/or walking and 6 hours sitting (8 hours total).”
We combined “standing and/or walking” into one question in the activity table.
We separated reaching into two questions for “reaching at/or below the shoulder” and “reaching overhead (above the shoulder)” and added boxes for one arm or both arms in the activity table.
We changed the wording of the question for using fingers and hands, added examples, and added boxes for one or both hands in the activity table.
We separated climbing into two questions for climbing stairs or ramps and climbing ladders, ropes, or scaffolds in the activity table.
We changed the question about weights lifted and carried to “Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you did it in a typical workday.”
We added an option for “less than 1 lb.” to the questions for heaviest weight lifted and weight frequently lifted.
We added a question “did the job expose you to any of the following with check boxes for outdoors, extreme heat (non-weather related), extreme cold (non-weather related), wetness, humidity, hazardous substances, moving mechanical parts, high exposed places, heavy vibration, loud noise, and other, and “if one or more boxes are checked, tell us about the exposure(s) and how often you were exposed.”
Justification #6: We made these changes to conform to the revised regulations for how we consider the period of time when we determine whether a person’s past work is relevant for purposes of disability determinations and decisions at steps four and five of the sequential evaluation process. We also revised questions and added examples to improve accuracy and usability.
Change #7: We added a question to “explain how your medical condition(s) affect your ability to do this job.
Justification #7: We made these changes to capture any additional work requirements and improve accuracy.
Change #8: We are updating the end of the form as follows:
We removed the statement “if other than the disabled person” to ask for the name, date, and signature of the person completing the form.
We revised the date format to MM/DD/YYYY.
We added a question to ask for the relationship to the person with a disability with check box options.
We added a question for the contact information when the person completing the form when not the person with a disability.
Justification #8: We made these changes to improve accuracy and usability, and for consistency with the revised SSA-454.
We will submit draft copies of the revised screens upon publication of the final rule. In addition, will implement the above revisions to the information collections upon the effective date of the Final Rule once we publish it. Once we implement the final rule, we will also submit Change Requests for each of the above-mentioned OMB Control Numbers (0960-0300, 0960‑0578, and 0960-0579) to submit the revised versions of the information collections, after which we will discontinue this new OMB number.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Naomi Sipple |
| File Modified | 0000-00-00 |
| File Created | 2023-10-03 |