Certification of Low Birth Weight for SSI Eligibility

Forms and Documents

Document	Type	Status	Availability
Form SSA-3830 Certification of Low Birth Weight for SSI Eligibility	Form	Modified	Available
Addendum - 0720.docx	Supplementary Document	Uploaded 2026-06-25	Available
Supporting Statement - 0720.docx	Supporting Statement A	Uploaded 2026-06-26	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
9777	Certification of Low Birth Weight for SSI Eligibility	Form	Modified	Certification of Low Birth Weight for SSI Eligibility

ICR Details

OMB Control No: 0960-0720	ICR Reference No: 202606-0960-002
Status: Received in OIRA	Previous ICR Reference No: 202010-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Certification of Low Birth Weight for SSI Eligibility
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/26/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2026
Responses	3,860	28,125
Time Burden (Hours)	1,287	7,031
Cost Burden (Dollars)	0	0

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Abstract: Hospitals and claimants use Form SSA-3830 to provide medical information to local field offices (FOs) and Disability Determinations Services (DDSs) on behalf of infants with low birth weight. FOs use the form as a protective filing statement, and the medical information to make presumptive disability findings, which allow expedited payment to eligible claimants. DDSs use the medical information from the SSA-3830 to determine disability and continuing disability. The respondents are hospitals and claimants who have information identifying low birth weight babies and their medical conditions.

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Authorizing Statute(s): US Code: 42 USC 1383b Name of Law: Social Security Act
   US Code: 42 USC 1382c 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:
	91 FR 22569	04/27/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 38748	06/26/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Certification of Low Birth Weight for SSI Eligibility	SSA-3830	Certification of Low Birth Weight for SSI Eligibility

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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	3,860	28,125	0	0	-24,265	0
Annual Time Burden (Hours)	1,287	7,031	0	0	-5,744	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 cleared this ICR in 2023, the burden was 7,031 hours. However, we are currently reporting a burden of 955 hours. The decrease in burden is due to a decrease in the number of respondents from 28,125 to 3,860. We believe this was an inadvertent overstatement of burden hours in the previous clearance, as we did not have accurate Management Information (MI) data at that time. Thes revised figures represent current, more accurate MI data. 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. These figures represent current Management Information data. *Note: The total burden reflected in ROCIS is 1,287 while the burden cited in #12 of the Supporting Statement is 965. This discrepancy is because the ROCIS burden also reflects the learning costs.

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Annual Cost to Federal Government: $24,814

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: 06/26/2026

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