Child-Care Dropout Questionnaire

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-4162 Child-Care Dropout Questionnaire	Form	Modified	Available
Form SSA-4162 Child-Care Dropout Questionnaire	Form	Modified	Repair queued
Justification for the Non-Substantive Changes - 0960-0474 (Removal of Signature Requirement ).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-04-30	Available
Justification for the Non-Substantive Changes - 0960-0474 (Removal of Signature Requirement ).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-04-30	Repair queued
Supporting Statement - 0474 (Final).docx	Supporting Statement A	Uploaded 2022-09-01	Available
Supporting Statement - 0474 (Final).docx	Supporting Statement A	Uploaded 2022-09-01	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9367	Child-Care Dropout Questionnaire	Form	Modified	Child-Care Dropout Questionnaire
9367	Child-Care Dropout Questionnaire	Form	Modified
9367	Child-Care Dropout Questionnaire	Other-Internal MCS Screens	Modified

ICR Details

OMB Control No: 0960-0474	ICR Reference No: 202404-0960-016
Status: Historical Active	Previous ICR Reference No: 202206-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Child-Care Dropout Questionnaire
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: 05/01/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/30/2024
Terms of Clearance: Approved consistent with the agency's commitments under Sec. 4 (k)(iii) and (iv) of E.O. 14058. Previous Terms of Clearance continue to apply: Prior to triannual renewal, the agency will modify Supporting Statement A, questions prompts #1 and #2 to provide additional discussion related to (1) the statutory authority under which the relevant regulations impacting this information collection were promulgated; (2) the policy goal of permitting the exclusion of years from the computation period; (3) the policy result if a claimant is successfully able to demonstrate they were maintaining a child under the age of 3. The agency is encouraged to provide examples of various scenarios related to this policy and how it impacts disability determinations or payments under Title II.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2026	04/30/2026	04/30/2026
Responses	1,563	0	1,563
Time Burden (Hours)	1,407	0	1,407
Cost Burden (Dollars)	0	0	0

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Abstract: The basic Social Security disability benefits application form (cleared under OMB No. 0960-0618) contains a lead question asking if the applicant cared for their own or their spouse’s children under age 3, and had no earnings during that period. If the answer is yes, the applicant completes Form SSA-4162 (either on paper or through a Social Security Administration (SSA) claims representative (CR) during a personal interview). SSA uses the information to determine if the applicant qualifies for the child-care exclusion. For the modernized claims system (MCS) application version, the beneficiary provides the information verbally to the SSA CR during a personal interview, and the CR inputs the information directly into the MCS application. The CR prints the MCS application for the beneficiary to verify and sign. Respondents are applicants for Title II disability benefits. 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 415 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 37899	06/24/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 52605	08/26/2022
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
Child-Care Dropout Questionnaire	SSA-4162	Child-Care Dropout Questionnaire

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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	1,563	1,563	0	0	0	0
Annual Time Burden (Hours)	1,407	1,407	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: When we last cleared this IC in 2019, the burden was 167 hours. However, we are currently reporting a burden of 261 hours. This change stems a decrease in the number of responses from 2,000 to 1,563. In addition, we updated our burden per response from 5 minutes to 10 minutes based on current Management Information data, and our reassessment of the burden to ensure we allow time for reading the instructions, gathering the data, and answering the questions. These figures represent current Management Information data. *Note: The total burden reflected in ROCIS is 1,407, while the burden cited in #12 of the Supporting Statement is 261. 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 of the Supporting Statement reflects actual burden.

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Annual Cost to Federal Government: $6,577

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: 04/30/2024

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