Disability Report - Adult

Forms and Documents

Document Name	Status
Form SSA-3368 Disability Report - Adult, (Fillable PDF) Form and Instruction	Unchanged
Justification for the Non-Substantive Changes - 0579.docx Justification for No Material/Nonsubstantive Change	2025-01-08
Supporting Statement - 0579 (Final).docx Supporting Statement A	2021-10-29

IC Document Collections

IC ID	Document Title	Status
9548	Disability Report - Adult, (Fillable PDF) Form and Instruction	Unchanged
179420	Disability Report - Adult, (Internet Version) Other-i3368 (Internet)	Modified
179419	Disability Report - Adult (EDCS Version) Other-EDCS	Unchanged

ICR Details

OMB Control No: 0960-0579	ICR Reference No: 202501-0960-002
Status: Received in OIRA	Previous ICR Reference No: 202104-0960-011
Agency/Subagency: SSA	Agency Tracking No:
Title: Disability Report - Adult
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/08/2025

	Requested	Previously Approved
Expiration Date	11/30/2026	11/30/2026
Responses	2,258,510	2,258,510
Time Burden (Hours)	3,387,766	3,387,766
Cost Burden (Dollars)	0	0

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Abstract: State Disability Determination Services (DDS) use Form SSA-3368, Disability Report – Adult, and its electronic versions, to determine if an adult disability applicant’s impairment(s) is severe and, if so, how the impairment(s) affects the applicant’s ability to work. This determination dictates whether the DDS and SSA will find the applicant disabled. The information we collect on the SSA 3368 is used by the State Disability Determination Services (DDS) to obtain evidence and evaluate whether or not an individual is found disabled. The collection is mandatory for applicants filing to obtain Title II disability benefits or Title XVI Supplemental Security Income (SSI) payments. We collect this information from the individual one time. We collect the information via several modalities: the SSA-3368-BK PDF paper form, the EDCS SSA-3368 Intranet application, and the i3368 Internet application. The respondents complete the SSA-3368 by themselves with self help information available, or another may complete the paper form or electronic application on their behalf. The respondents generally do not need information from someone else to complete the application. The respondents are disability applicants or third parties assisting the applicants applying for Title II disability benefits or Title XVI SSI payments. We are submitting a non-substantive Change Request to revise the informational langauge on the save and exit screens for the Internet modallity, i3368.

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Authorizing Statute(s): US Code: 42 USC 205(a) Name of Law: The Social Security Act
   US Code: 42 USC 223(d)(5)(A) Name of Law: The Social Security Act
   US Code: 42 USC 1631(e)(1) Name of Law: The Social Security Act
   US Code: 42 USC 1631(d)(1) Name of Law: The 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:
	86 FR 46897	08/20/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 59262	10/26/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Disability Report - Adult (EDCS Version)
Disability Report - Adult, (Fillable PDF)	SSA-3368	Disability Report - Adult
Disability Report - Adult, (Internet Version)

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ICR Summary of Burden

	Total Request	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	2,258,510	2,258,510	0	0	0	0
Annual Time Burden (Hours)	3,387,766	3,387,766	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: $49,426,830

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: 01/08/2025

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