Supporting Statement - 0577 (Revised)

Supporting Statement for Form SSA-3820-BK

Disability Report-Child

20 CFR 416.912

OMB No. 0960-0577

1. Justification

1. Introduction/Authorizing Laws and Regulations

Sections 205(a) and 1631(d)(1) of the Social Security Act (Act), provide the Commissioner of the Social Security Administration (SSA) 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 needed, as well as the methods of taking and furnishing the same, to evaluate an alleged disability. Sections 223(d)(5)(A) and 1631(e)(1) of the Act require that claimants for SSA benefits furnish such medical and other evidence of disability as the Commissioner may require to prove they are disabled. 20 CFR 416.912 of the Code of Federal Regulations, specifically states, among other things, that individuals will furnish medical evidence and, if asked, evidence of age; education and training; work experience; efforts to work; and any other evidence showing how their impairment(s) affects the ability to work, or in the case of a child, the ability to function.

2. Description of Collection

Form SSA-3820-BK is a collection of information submitted for a child applying for Supplemental Security Income (SSI) disability payments. SSA uses Form SSA-3820-BK to collect information about a child’s condition from treating sources or other medical sources of evidence. The State Disability Determination Services (DDS) evaluators use the information from Form SSA-3820-BK, and its electronic versions, to develop medical and school evidence, and to assess the alleged disability. The information collected on the form, together with medical evidence and other sources of non-medical evidence, provides the evidentiary basis upon which SSA makes its initial disability evaluation. Information collected on the SSA-3820-BK includes biographic information, detailed medical history, education history, and work history. The respondents are claimants seeking SSI childhood disability payments.

As discussed in additional detail below, submitting an SSI application requires multiple forms. While the SSA-3820-BK is used by the respondent to provide substantial detail regarding the claimant’s history, it is separate from the application form itself, which is SSA-16 (OMB No. 0960-0618). Additionally, a respondent must also complete the SSA-827 ("Authorization to Disclose Information to the Social Security Administration," OMB No. 0960-0623), which empowers SSA to request documentation directly from medical and non-medical sources like doctors and schools, and may need to complete other forms relevant to the circumstances of the application dependent on need. (For example, most respondents will need to complete one of the Child Function Reports depending on the age of the child (SSA-3375-3379, OMB No. 0960-0542). SSA staff inform respondents as to which other forms they need to complete once they submit the SSA-3820-BK, or the i3820 Internet application. Applicants can complete the child disability report online via the i3820 or use the paper Form SSA-3820-BK, which respondents can either mail in or hand-deliver. When a respondent completes the i3820, the system generates a notification page that respondents can bring to the local Social Security field office (FO) to continue the application process. However, the notification page serves as a back-up alert to the FOs that an applicant transmitted an online childhood disability report. If the respondent has not already completed an application, then upon submission of the i3820, the local FO will directly initiate contact with the respondent to complete the application process. When claimants do not complete an i3820, and instead submit the information on the SSA-3820-BK either via the paper form or personal interview (either over the phone or in an FO), FO employees use the Intranet Electronic Disability Collect System (EDCS) to record the information for the DDS adjudicators.

The respondents are applicants, claimants, beneficiaries, or recipients filing for reconsideration of an initial determination.

3. Use of Information Technology to Collect the Information

SSA has an online child disability report, the i3820, which allows respondents to document all of the information present on the paper SSA-3820-BK. Upon completion, the information propagates into EDCS. However, completion of the online child disability report does not constitute submission of a completed SSI application as SSA requires the respondent to separately submit the SSI application, either via an in-person field office visit or a phone interview. Moreover, respondents cannot submit any supplemental documentation they may have, which must be transmitted either via mail or hand delivery to an SSA field office. Finally, respondents must also submit the SSA-827 (0960-0623), which empowers SSA to request documentation directly from medical and non-medical sources like doctors and schools. Approximately 50% of respondents submit the information via the i3820.

When a respondent submits their information either via the paper Form

SSA-3820-BK or via an interview (either over the phone or in a Field Office) the SSA technician will directly enter responses into the Intranet EDCS screens, which creates an electronic record that the DDS office uses when reviewing and adjudicating the application.

Respondents are able to electronically submit the information required under 0960-0577, as described under GPEA, via the i3820 online child disability report. However, other aspects of the SSI application process for children, which may include the SSA-3375-3379 (which can only be mailed in or responded to orally), if needed based on the circumstances of a claim, do not have electronic submission capabilities. SSA actively encourages respondents who complete the i3820 to visit or call their local field office as the next step in the application process.

4. 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-3820-BK, the public would have no way to apply for disability benefits for children. Because we only collect the information once, 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 July 3, 2019, at

84 FR 31972, and we received no public comments. The 30-day FRN published on September 16, 2019 at 84 FR 48694. If we receive any comments in response to this Notice, we will forward them to OMB.

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 Completion	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollars)*	Total Annual Opportunity Cost (dollars)**
SSA-3820	177,572	1	90	266,358	$10.22	$1,814,786**
EDCS	1,000	1	120	2,000	$10.22	$10,220**
i3820	176,572	1	120	353,144	$10.22	$1,804,566**
Totals	355,144			621,502		$3,629,572**

* We based this figure on average DI payments, as reported in SSA’s disability insurance payment 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 application. There is no actual charge to respondents to complete the application.

The total burden for this ICR is 621,502 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $3,629,572. SSA does not charge respondents to complete our applications.

13. Annual Cost to the Respondents

This collection does not impose a known cost burden on the respondents.

14. Annual Cost to Federal Government

The estimated annual cost to the Federal government is approximately $751,220.

This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time; and (3) systems development, updating, and maintenance costs.

15. Program Changes or Adjustments to the Information Collection Request

When we last cleared this IC in 2016, the burden was 659,431 hours. However, we are currently reporting a burden of 621,502 hours. This change stems a decrease in the number of responses from 659,431 to 621,502. 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.

16. Plan for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

For the paper Form SSA-3820-BK, 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 (for example, 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.

For the Internet version of form SSA-3820-BK (i3820), SSA is not requesting an exception to the requirement to display the OMB approval expiration date.

18. Exemptions 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).

2. Collection of Information Employing Statistical Methods

SSA will not use statistical methods for this information collection.

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