Title of Information Collection and Form Number(s)

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html

Supporting Statement for Form SSA-3380-BK
Function Report – Adult Third Party
20 CFR 404.1512, 404.1564, 416.912, and 416.964
OMB No. 0960-0635

A. 	Justification

    1. Introduction/Authoring Laws and Regulations
Sections 205(a), 223(d)(5)(A), 1631(d)(1), and 1631(e)(1) of the Social Security Act (Act) require individuals receiving or applying for Social Security disability benefits to provide the Social Security Administration (SSA) with medical and other evidence of their disability.  These sections of the Act also grant the SSA the authority to establish procedures for collecting and verifying this evidence.  Sections 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations provide detailed requirements for the types of evidence Social Security disability claimants and beneficiaries must provide showing how their impairments affect their ability to work (e.g., evidence of age; education and training; work experience; daily activities; efforts to work).  SSA uses Form SSA-3380, Function Report Adult-Third Party, to collect the information for adult disability cases.

    2. Description of Collection
SSA requires individuals receiving or applying for Social Security Disability Insurance (SSDI), or Supplemental Security Income (SSI) to provide medical evidence and other proof to prove their disability.  After completion of the initial application form, which is covered under OMB No. 0960-0618 (iClaim or the SSA-16) for SSDI applicants and OMB Nos. 0960-0229 (SSA-8000) or 0960-0444 (SSA-8001, an abbreviated version of the SSA-8000) for SSI applicants, SSA typically requests that respondents complete a series of additional forms that support the development of the necessary disability evidence. 

Two of these forms are the disability reports (SSA-3368 or f or the SSA-3820 for children), which are covered under OMB Control Numbers 0960-0579 and 0960-0577, respectively.  The disability reports help SSA understand the claimant’s medical conditions, medical treatments (including sources of potential medical evidence), and other information (including work activity, job history, education and training, and vocational rehabilitation).  After which we ask either the claimant or a third party who knows the claimant to complete the Function Report forms (SSA-3380, and SSA-3373).

We designed the Function Report forms specifically to develop evidence related to the claimant’s ability to function and perform the activities of daily living.  When claimants are capable of completing the Function Report on their own behalf, they complete and submit the SSA-3373 (covered under OMB Control 0960-0681).  In addition, most often we ask third parties who know the claimant’s abilities to complete the Function Report – Adult Third Party, Form SSA‑3380-BK, in addition to the claimants’ self‑reports using the SSA-3373.

To collect the information we request on the SSA-3373, SSA or the Disability Determination Services (DDSs) commonly start by contacting the third‑party contact listed in section 2 of the SSA-3368.  SSA or DDSs can also contact the claimant to determine potentially helpful third-party respondents, depending on case facts, e.g., we may want the perspective of a coworker, or a social worker.  In some cases, SSA and DDSs may obtain multiple third-party reports, however, this is an uncommon occurrence.  SSA informs nonmedical source(s) we are seeking information in connection with a claim for Social Security benefits, and our guidance instructs adjudicators to take care to preserve the claimant's privacy, for instance we do not reveal that the claimant has a mental impairment, and our policy is to keep information to a minimum when disclosing information to third parties.

Typically, SSA or the DDS sends Form SSA-3380 to the third party, which is how the third party learns about the form.  SSA or the DDS does not send an on-file SSA-827, Authorization for Source to Release Information to SSA, covered under 0960-0623, unless the SSA or DDS technician knows from past experience the source requires it.  In the rare instance in which a third party requests an SSA-827, SSA or the DDS effectively blacks out all but the last four digits of the claimant’s SSN previously entered on the SSA-827.  

In most cases, SSA or a DDS typically determines that we need a third party to complete the Functional Report when we need additional information to fully evaluate a claimant's limitations in the ability to function.  At that time, we ask a third party to complete a Function Report about a claimant.  For example, the adjudicator may find it necessary to request a Function Report from a third party if a claimant’s mental impairments compromise their ability to self-report.  SSA or the DDS identifies the third party by seeking this information  from sources who have observed the claimant on a long-term basis, are knowledgeable about the claimant's current day-to-day functioning, and can contrast this to the claimant's “premorbid” functioning, if relevant.  Examples of knowledgeable third parties include educational personnel, public and private social welfare agency personnel, family members, caregivers, friends, neighbors, employers, and clergy.  We prefer to request the information from people either living with the claimant or those in close contact with the claimant. 

We do not require completion of Form SSA-3380 in all instances, although we request it for roughly 17% of applications.  If  SSA or the DDS determines that this additional information from a third party would be helpful in adjudicating the claim, typically, we mail the SSA-3380 to the identified third party to complete.  If, however, the third party requires assistance to complete the form or they do not respond to the mailed form, SSA or the DDS contact the respondent and collect the information by phone.  In an effort to modernize and make this process easier for claimants, on August 29, 2026, SSA implemented an electronic version of this form that claimant’s representative payees can complete and submit online through SSA’s Upload Documents Portal (OMB No. 0960‑0830).  This provides an online service option to representative payees as an alternative to mailing, faxing, or bringing the form to an SSA field office.  SSA plans to expand availability of this online option to any third-party respondent once we can update the system to allow for reliable routing of the form to the claimant’s file. 
There are no identifiable psychological or learning burdens associated with this information collection, because we are not asking the respondents to provide sensitive or personal information., and we have received no feedback on the form indicating that respondents have issues in completing the documentation.

The respondents are third parties familiar with the functional limitations (or lack thereof) of claimants who apply for SSI and SSDI payments.

    3. Use of Information Technology to Collect the Information
Form SSA-3380 is available as a fillable PDF on SSA’s website, which the respondent completes, prints, and mails to SSA.  More commonly, SSA or the DDS mails the paper form to the respondent to complete and return to SSA.  

In addition, we created a public-facing fillable and submittable version which some respondents can submit electronically using SSA’s Upload Documents Portal (OMB No. 0960‑0830).  Upload Documents allows the respondent to complete the fillable PDF, electronically sign it and submit the information through the Upload Documents Portal.  The submittable version mirrors the paper version and provides respondents with an online service option as an alternative to mailing, faxing, or bringing the form to an SSA field office.  Use of the Upload Documents Portal does not require respondents to download and install the application locally on their device or pay any subscription or licensing fees, and we account for the burden for using Upload Documents under OMB No. 0960-0830.  SSA implemented the Upload Documents modality for Form SSA-3380 on 8/29/26, therefore we do not have any current MI data at this time, so we have included the burden in #12 below for the Upload Documents respondents under the main paper form.

This collection does not currently have a fully public-facing Internet version, as we prioritized other information collections for full electronic conversions.  Given that IT Mod programming is an ongoing, dynamic project, we cannot provide specific timelines for when we will be able to make any particular ICR available via Internet web-based application.  We will ultimately convert most existing ICRs to full electronic versions depending on how they fall within our overall IT Mod schema, but this may be unconnected to the PRA approval lifecycle.

    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 SSA did not collect this information, we would be unable to adjudicate many new claims for disability benefits or make determinations on continuing eligibility for benefits, leaving us unable to fulfill our mandate to make payments to those who are disabled.  Because we ask the respondents to complete the form only once for an initial adult claim for benefits and occasionally again in the case of a continuing disability review or appeal, we cannot collect the information 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 31, 2026, at 91 FR 48470, and we received no public comments.  The 30-day FRN published on September 24, 2026, at 91 FR 60677.  If we receive any comments in response to this Notice, we will forward them to OMB.  We did not consult with the public in the development revision of this form.

    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
Please see the burden chart below:
	
Method
of Completion
Number 
of Respondents
Frequency
of 
Response
Average Burden Per Response (minutes)
Estimated Total Annual Burden (hours) 
Average Theoretical Cost Amount (dollars)*
Total Annual Opportunity Cost (dollars) ***
SSA-3380-BK 
635,620
1
61
646,214
$33.54*
$21,674,018**
* We based this figure on the average U.S. worker’s hourly wages, as reported by Bureau of Labor Statistics data (Occupational Employment and Wage Statistics

** This figure does not represent actual costs that SSA is imposing individuals; rather, these are theoretical opportunity costs for the addition time respondents will spend to complete the information collection.  There is no actual charge to respondents to complete the application.
We did not include travel time as per our current management information data, respondents who complete the paper forms return them to us via mail only, and those who use Upload Documents complete and submit the form entirely electronically.  Should this change in the future, we will include the language and chart for travel time to a field office.  

We calculated the following Learning Cost time burden based on the estimated time and effort we expect respondents will take to learn about this program, its applicability to their circumstances, and to cover any additional research we believe respondents may need to take to understand how to comply with the program requirements (beyond reading the instructions on the collection instrument):

Total Number of Respondents 
Frequency of Response
Estimate Learning Cost (minutes)
Estimated Total Annual Burden (hours)
Total Annual Learning Cost (dollars)*****
635,620
1
5
52,968
 $1,776,547
*****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

NOTE:  We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates in the paragraph below.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection.  Per our management information data, we believe that 61 minutes accurately shows the average burden per response for learning about the program; receiving notices as needed; reading and understanding instructions; gathering the data and documents needed; answering the questions and completing the information collection instrument; scheduling any necessary appointment or required phone call; consulting with any third parties (as needed); and waiting to speak with SSA employees (as needed).  Based on our current management information data, the current burden information we provided is accurate.  The total burden for this ICR is 646,214 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $23,450,565.  SSA does not charge respondents to complete our applications.

13. 	Annual Cost to the Respondents (Other) 
This collection does not impose a known cost burden on the respondents.   

    14. Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $7,687,765.  This estimate accounts for costs from the following areas:

Description of Cost Factor
Methodology for Estimating Cost
Cost in Dollars*
Designing and Printing the Form
Design Cost + Printing Cost
$1,158
 
Distribution, Shipping, and Material Costs for the Form
Distribution + Shipping + Material Cost
$0**
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time
GS-9 employee x # of responses x processing time
$7,683,480 


Full-Time Equivalent Costs
Out of pocket costs + Other expenses for providing this service
$0*
Systems Development, Updating, and Maintenance
GS-9 employee x man hours for development, updating, maintenance
$3,126
Quantifiable IT Costs
Any additional IT costs
$0*
Total

$7,687,765
* We have inserted a $0 amount for cost factors that do not apply to this collection.
** We do not track this data any longer as we do not require the DDSs to report distribution or shipping costs as a budget line item.  In addition, since these costs vary per DDS, we cannot accurately speculate the percentage of the overall distribution and shipping costs from the overall budget reports from the DDSs.
SSA is unable to break down the costs to the Federal government further than we already have.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.
15.	Program Changes or Adjustments to the Information Collection Request
When we last cleared this IC in 2023, the burden was 721,528 hours.  However, we are currently reporting a burden of 646,214  hours.  This change stems from a decrease in the number of responses and an increase in burden time per response.  Responses decreased from 709,700 to 635,620.  Although the number of responses changed, SSA did not take any actions to cause this change.  These figures represent current Management Information data.  In addition, the burden time increased by five minutes per response due to learning costs that we did not include in our last theoretical burden calculation.  

*Note: The total burden reflected in ROCIS is 6,99,182, while the burden cited in #12 of the Supporting Statement is 646,214.  This discrepancy is because the ROCIS burden reflects the learning costs.  In contrast, the chart in #12 above reflects actual burden.

16.  	Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.


17.	Displaying the OMB Approval Expiration Date
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 (e.g., 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. 

    18. Exceptions 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).

B.     	Collections of Information Employing Statistical Methods

	SSA does not use statistical methods for this information collection.