Pain Report - Child

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-3371-BK Pain Report-Child	Form	Modified	Available
10-26-26 - Comment from the National Coalition of Social Security and Supplemental Security Income Advocates.pdf	Public Comments	Uploaded 2026-10-29	Available
Addendum - 0540 (Final).docx	Supplementary Document	Uploaded 2026-10-29	Available
Supporting Statement - 0540 (Final).docx	Supporting Statement A	Uploaded 2026-10-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9452	Pain Report - Child	Form	Modified	Pain Report-Child
9452	Pain Report - Child	Other-Privacy Act Statement (revised) 0540	Modified

ICR Details

OMB Control No: 0960-0540	ICR Reference No: 202609-0960-007
Status: Received in OIRA	Previous ICR Reference No: 202112-0960-006
Agency/Subagency: SSA	Agency Tracking No:
Title: Pain Report - Child
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/29/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2026
Responses	1,602	1,500
Time Burden (Hours)	2,163	1,725
Cost Burden (Dollars)	0	0

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Abstract: SSA requests information on Form SSA-3371-BK to provide disability interviewers, as well as applicants or claimants in self-help situations, with a convenient means to record information about the claimant's pain or other symptoms. The State disability determination services (DDS) adjudicators and administrative law judges then use the information to assess the effects of symptoms on function for purposes of determining disability under the Social Security Act. The respondents are applicants for or claimants of Supplemental Security Income (SSI) benefits.

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Authorizing Statute(s): US Code: 42 USC 1382c Name of Law: Social Security Act
   US Code: 42 USC 1383 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 55421	08/27/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 68213	10/29/2026
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
Pain Report - Child	SSA-3371-BK	Pain Report-Child

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ICR Summary of Burden

table that charts list 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	1,602	1,500	0	0	102	0
Annual Time Burden (Hours)	2,163	1,725	0	0	438	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 2023, the burden was 375 hours. We are currently reporting a burden of 401 hours. This minor change is due to a slight increase in the number of average responses per year from 1,500 to 1,602 total responses. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any action(s) to cause this change. These figures represent current management information data. *Note: The total burden reflected in ROCIS is 2,163, while the burden cited in #12 of the Supporting Statement is 401. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + telephone call system wait times + learning costs + a rough estimate of a 30-minute, one-way, drive burden. In contrast, the chart in #12 above reflects actual burden.

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Annual Cost to Federal Government: $15,534

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: 10/29/2026

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