Title of Information Collection and Form Number(s)

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Supporting Statement for Pain Report - Child
Form SSA-3371-BK
20 CFR 416.912, 404.512
OMB No. 0960-0540

A. 	Justification

    1. Introduction/Authoring Laws and Regulations
Sections 1614 (a)(3)(H)(i) and 1631(e)(1) of the Social Security Act (Act) require claimants for SSA benefits to furnish medical and other evidence of disability as required to prove their disability.  Disability regulations in 20 CFR 416.912 and 404.512 require individuals to provide medical evidence and, if asked, evidence of age; education; training; work experience; daily activities; efforts to work; and any other evidence showing how their impairment(s) affects the ability to work or, in the case of a child, how the claimant functions.  Section 1631(d)(1) of the Act provides the Commissioner of the Social Security Administration (SSA) with the full power and authority to make rules and regulations, establish procedures, and to adopt reasonable and proper rules for the nature and extent of the evidence as well as the methods of taking and furnishing the same to evaluate the alleged disability.  

    2. Description of Collection
When parents, guardians, agencies, or other appropriate individuals file an application for Supplemental Security Income (SSI) disability benefits on behalf of a child, SSA requires evidence to make a disability determination. 

A disability adjudicator, either a State Disability Determination Services (DDS) employee or a federal SSA employee initiates Form SSA-3371-BK to obtain information SSA needs for case development.  When an adjudicator needs additional information about the child’s pain, the adjudicator mails Form SSA-3371-BK to the appropriate individual for completion and return to SSA or the DDS.  SSA may send the
SSA-3371-BK separately or with other childhood disability forms, such as the child function report (OMB No. 0960-0542).  

Form SSA-3371-BK asks individuals who know about the child’s disability to provide detailed information about the location of the child’s pain, how long the pain lasts, how often the pain occurs, what causes or worsens the pain, and any medication(s) or treatment(s) the individual uses to relieve pain.   Adjudicators and judges use the information Form SSA-3371-BK provides along with other medical and non-medical evidence to determine how the child’s pain affects the child’s ability to function.  If the individual does not return Form SSA-3371-BK to SSA or the DDS, the technician begins the case development procedures without the form and evidence.

We identified the following psychological costs based on the requirements for this information collection:


Psychological Costs:
    • Requirement for Program:  Form SSA-3371-BK requires respondents to provide personal information about the child’s pain, including the location, causes, and severity of the pain, as well as types of medication and/or treatment that alleviates the pain.

    • Psychological Costs: Despite the value of the information Form SSA-3371-BK collects,  the respondent may fail to respond, delay completing the form, or provide incomplete feedback due to perceiving the information requested as invasive.   

We understand these psychological costs may cause respondents to delay their completion of the information collection or cause them to abandon the information collection entirely.  However, we require full completion of this collection to receive benefits.  Therefore, we have taken this potential psychological cost into account when calculating our burden in #12 below.
The respondents are parents, guardians, or individuals who know a child SSI applicant or recipient well.

    3. Use of Information Technology to Collect the Information
Form SSA-3371-BK is available on SSA’s website for respondents to print and mail back to SSA, or complete in a field office.  In addition, adjudicators mail Form SSA-3371-BK to the respondents.

This collection has a public-facing fillable and submittable version which the respondent can submit 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-3371-BK on 8/29/26, therefore we do not have any current MI data for the use of this form in Upload Documents at this time.  We will update our burden data for the Upload Documents version of the form once we have the available MI data.

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
We coordinated the development and revision of other forms used in childhood disability cases to avoid duplication.  When initially applying for SSI, the adult responsible for child (parent, guardian, caregiver, etc.) fills out the SSA-3820 Disability Report – Child (OMB No. 0960‑0577), as well as one of the SSA-3375-BK through SSA-3379-BK (OMB No. 0960-0542), as relevant to the child’s age.  Additionally, we collect information about the child’s functioning from teachers and administrators, who fill out the SSA-5665 and SSA-5666 (OMB No. 0960-0646).

While the other forms used in childhood disability cases obtain some similar information, the nature of the information we collect on the SSA-3371-BK and the manner in which we collect it preclude duplication.  SSA does not use another collection instrument to obtain similar data or information specific to a child’s pain.  

    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 we did not use Form SSA-3371-BK, non-standardized requests for information on the child’s pain would vary and it would compromise SSA’s ability to make accurate and supportable disability determinations in childhood SSI disability reviews.  Because we only collect the information on as needed basis, we cannot collect it 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 August 27, 2026, at 91 FR 55421, and we received 1 public comment.  Please see the Addendum for the summary of the public comment and SSA’s responses.  The 30-day FRN published on October 29, 2026, at 91 FR 68213.  If we receive any comments in response to this Notice, we will forward them to OMB.  We did not consult with the public for the 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)*
Average Wait Time in Field Office or Teleservice Centers (minutes)**
Total Annual Opportunity Cost (dollars) ***
SSA-3371 (Upload Documents and Paper)

1,602
1
15
401
$23.91*
21**
$9,588***
* We based these figures on the combined average of both disability payments ($14.27) based on SSA's current FY 2026 data (Effect of COLA on Average Social Security Benefits) and on the average U.S. worker’s hourly wages ($33.54), as reported by Bureau of Labor Statistics data (Occupational Employment and Wage Statistics).

** We based this figure on the average FY 2026 wait time for field offices (21 minutes), based on SSA’s current management information data.  This figure reflects data from our systems and the data posted on our public facing website (Social Security performance |SSA) on the date we drafted this document.  As the figures fluctuate, the wait times may be different on the website than they appear here.  While we have included wait time for all respondents, we note that respondents are not required to complete the form in person and those who mail or drop off a completed form do not experience any wait time.

*** This figure does not represent actual costs that SSA is imposing on individuals; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the information collection.  There is no actual charge to respondents to complete the information collection.

In addition, OMB’s Office of Information and Regulatory Affairs (OIRA) is requiring SSA to use a rough estimate of a 30-minute, one-way, drive time in our calculations of the time burden for this collection.  OIRA based their estimation on a spatial analysis of SSA’s current field office locations and the location of the average population centers based on census tract information, which likely represents a 13.97 mile driving distance for one-way travel.  We depict this on the chart below:

Total Number of Respondents Who Visit a Field Office
Frequency of Response
Average One-Way Travel Time to a Field Office (minutes)
Estimated Total Travel Time to a Field Office (hours)
Total Annual Opportunity Cost for Travel Time (dollars)****
1,602
1
30
801
$19,152****
****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

Per OIRA, we include this travel time burden estimate under the 5 CFR 1320.8(a)(4), which requires us to provide “time, effort, or financial resources expended by persons [for]…transmitting, or otherwise disclosing the information,” as well as 5 CFR 1320.8(b)(3)(iii) which requires us to estimate “the average burden collection…to the extent practicable.”  SSA notes that we do not obtain or maintain any data on travel times to a field office, nor do we have any data which shows that the average respondent drives to a field office, rather than using any other mode of transport.  SSA also acknowledges that respondents’ mode of travel and, therefore, travel times vary widely dependent on region, mode of travel, and actual proximity to a field office.

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 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)*****
1,602
1
15
401
$9,588*****
*****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 15 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 401 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $38,328.  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 $15,534.  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
$1,609
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
$4,110
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
$9,815
Quantifiable IT Costs
Any additional IT costs
$0*
Total

$15,534
* 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.  First, since we work with almost every US citizen, we often do bulk mailings and cannot track the cost for a single mailing.  In addition, it is difficult for us to break down the cost for processing a single form, as field office and State Disability Determination Services staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent.  Also, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  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 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.

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

17.	Displaying the OMB Approval Expiration Date
[Use the template language that works best here].

    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.