Function Report - Adult

Forms and Documents

Document Name	Status
Form SSA-3373-BK Function Report - Adult Form and Instruction	Modified
RE OMB comments on Function Report - Adult (0960-0681) .htm Supplementary Document	2006-10-16
SSA-3373 (0960-0681) addendum.doc Supplementary Document	2006-08-18
SSA-3373 (0960-0681) supporting statement.doc Supporting Statement A	2006-08-18

IC Document Collections

IC ID	Document Title	Status
9735	Function Report - Adult Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0681	ICR Reference No: 200608-0960-008
Status: Historical Active	Previous ICR Reference No: 200310-0960-012
Agency/Subagency: SSA	Agency Tracking No:
Title: Function Report - Adult
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/17/2006
	Date Received in OIRA: 08/21/2006
Terms of Clearance: This form is a potential electronic candidate under SSA's GPEA implementation plan. SSA plans to evaluate this form for electronic conversion within the next few years. OMB approves this form with the understanding that upon resubmission of this form for OMB approval, SSA will have completed this evaluation and will provide OMB with a full report of the results of the evaluation.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2009	36 Months From Approved	12/31/2006
Responses	4,005,367	0	4,005,367
Time Burden (Hours)	4,005,367	0	2,002,684
Cost Burden (Dollars)	0	0	0

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Abstract: Form SSA-3373-BK is used to collect information about a disability applicant's or recipient's impairment-related limitations and ability to function. This information, together with medical evidence, forms the evidentiary basis upon which the initial disability process is founded. The respondents are Title II and Title XVI applicants(or current recipients undergoing redeterminations for) disability benefits.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: null
   US Code: 42 USC 423 Name of Law: null
   US Code: 42 USC 1383 Name of Law: null
  

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:
	71 FR 30464	05/26/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 45090	08/08/2006
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
Function Report - Adult	SSA-3373-BK, SSA-3373	Function Report - Adult (Current Version with no Revisions) ,   Function Report - Adult (Version with Proposed Revisions)

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ICR Summary of Burden

	Total Approved	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	4,005,367	4,005,367	0	0	0	0
Annual Time Burden (Hours)	4,005,367	2,002,684	0	1,001,342	1,001,341	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The increase in response time and resulting total burden is due to 1) complaints SSA received that its original estimate was too low and 2) the fact that we have added a number of new questions to this form (see attached addendum for detailed explanations).

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Annual Cost to Federal Government: $37,009,591

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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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: 08/21/2006

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