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Federal forms, ICRs, and supporting documents

OMB control number

Certification of Low Birth Weight for SSI Eligibility

OMB 0960-0720 · SSA.

OMB 0960-0720

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.

The latest form for Certification of Low Birth Weight for SSI Eligibility expires 2026-07-31 and is listed under ICR 202010-0960-007.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form SSA-3830 Certification of Low Birth Weight for SSI EligibilityForm
Addendum - 0720.docxSupplementary Document
Supporting Statement - 0720.docxSupporting Statement A
Certification of Low Birth Weight for SSI Eligibility Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202606-0960-002 Revision of a currently approved collection 2026-06-26
202010-0960-007 Revision of a currently approved collection 2021-01-28 Approved with change
201709-0960-001 Revision of a currently approved collection 2017-12-29 Approved without change
201409-0960-004 Revision of a currently approved collection 2014-12-09 Approved without change
201112-0960-001 Revision of a currently approved collection 2012-03-26 Approved without change
200811-0960-009 Revision of a currently approved collection 2009-04-21 Approved without change
200603-0960-001 New collection (Request for a new OMB Control Number) 2006-03-06 Approved with change