Report of Adult Functioning-Employer

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-3385 Report of Adult Functioning-Employer	Form	Modified	Available
Form SSA-3385 Report of Adult Functioning-Employer	Form	Modified	Repair queued
Justification for the Non-Substantive Changes - 0960-0805 (Removal of Signature Requirement)).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-04-26	Available
Justification for the Non-Substantive Changes - 0960-0805 (Removal of Signature Requirement)).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-04-26	Repair queued
Justification for a Non-Substantive Change 0960-0805.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-02-22	Repair queued
Justification for a Non-Substantive Change 0960-0805.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-02-22	Repair queued
Supporting Statement - 0805 (Clean Copy).docx	Supporting Statement A	Uploaded 2023-08-24	Available
Supporting Statement - 0805 (Clean Copy).docx	Supporting Statement A	Uploaded 2023-08-24	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
221156	Report of Adult Functioning-Employer	Form	Modified	Report of Adult Functioning-Employer
221156	Report of Adult Functioning-Employer	Form	Modified

ICR Details

OMB Control No: 0960-0805	ICR Reference No: 202404-0960-008
Status: Active	Previous ICR Reference No: 202402-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Report of Adult Functioning-Employer
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/29/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/26/2024
Terms of Clearance: Approved consistent with the agency's commitments under Sec. 4 (k)(iii) and (iv) of E.O. 14058.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2026	08/31/2026	08/31/2026
Responses	3,601	0	3,601
Time Burden (Hours)	1,200	0	1,200
Cost Burden (Dollars)	0	0	0

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Abstract: Under the authority provided in sections 205(a), 223(d)(5)(A), 1631(d)(1), and 1631(e)(1) of the Act, the agency may collect information from each applicant for, or recipient of (collectively referred to as ‘‘claimant’’), disability insurance benefits (DIB) or SSI payments. We use this information as evidence to help us determine eligibility or continued eligibility for DIB or SSI. These sections of the Act grant us the authority to establish procedures for collecting and verifying this evidence. Sections 20 CFR 404.1512 and 20 CFR 416.912 of the Code of Federal Regulations provide detailed requirements for the types of evidence we request claimants provide showing how their impairment(s) affects their ability to work (e.g., medical, work experience, daily activities, efforts to work). When SSA’s Disability Determination Service adjudicative team determines that SSA needs additional information to process an applicant’s or claimant’s case, we use Form SSA-3385, Report of Adult Functioning – Employer, to collect information from a claimant’s current or former employer on an as needed basis, to collect information regarding the claimant’s job performance as evidence to help inform the disability eligibility for the claimant. We send the SSA-3385 with a pre addressed and stamped envelope to a claimant’s direct supervisor, or another person who has direct knowledge of the claimant’s job performance and ask that individual to provide information about the claimant’s day-to-day functioning in a work setting. The respondent completes Form SSA-3385 and sends it back to SSA in the enclosed envelope. Once SSA receives the SSA-3385, the field office scans the form into the claimant’s electronic folder. Then the Disability Determination Service adjudicative team uses this information to evaluate the claimant’s impairment-related functional limitations to determine eligibility or continued eligibility for SSDI or SSI. The respondents are current or former employers who are contacted only when the adjudicative team decides additional information is necessary and the employer may be a good source for the information. We are submitting this non-substantive change to remove the signature line and replace the Penalty of Perjury Statement with a Penalty of Perjury Warning.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 1381 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:
	87 FR 44180	07/25/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 60721	10/06/2022
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
Report of Adult Functioning-Employer	SSA-3385	Report of Adult Functioning-Employer

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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	3,601	3,601	0	0	0	0
Annual Time Burden (Hours)	1,200	1,200	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: $3,643

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: 04/26/2024

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