OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Work History Report

ICR 200702-0960-002 · OMB 0960-0578 · Historical Active

Forms and Documents
Document
Name
Status
Form
 Modified
Supporting Statement A
2007-07-23
Supplementary Document
2007-07-10
Supplementary Document
2007-03-22
Supplementary Document
2007-02-15
IC Document Collections
IC ID
Document
Title
Status
9542 Modified
181136 New
ICR Details
0960-0578 200702-0960-002
Historical Active 200406-0960-004
SSA
Work History Report
Revision of a currently approved collection   No
Regular
Approved with change 12/07/2007
Retrieve Notice of Action (NOA) 07/25/2007
This ICR is approved on the understanding that SSA will, within the next 36 months and prior to renewal of this ICR, convene two focus groups of (a) disability adjudicators and (b) SSA claimants/benes. Anecdotal evidence suggests that claimants have difficulty with the parts of this form that ask them to break down their daily work activities by the hour (i.e. "in this job, how many total hours each day did you crouch, kneel, stoop," etc.). In turn, SSA adjudicators may need to follow-up with claimants to get the information they need because they could not obtain it through the form. The purpose of these focus groups will be to evaluate the utility of this question and to assess the extent to which utility could be improved. SSA agrees to ask adjudicators questions such as "how ofen is the information provided on this form incomplete, unreliable, or otherwise inadequate, requiring you to follow-up with the claimant to get the information required?" Questions to be asked of claimants include questions like "how easy or difficult do you find this question to answer?"
  Inventory as of this Action Requested Previously Approved
12/31/2010 36 Months From Approved 12/31/2007
449,500 0 871,000
449,500 0 871,000
0 0 0
The SSA-3369-BK is used to document an applicant's work history. The information is used by Disability Determination Services (DDS) to make a decision about the alleged disability. The respondents are applicants for disability benefits.
US Code: 42 USC 423 Name of Law: null
  
None
Not associated with rulemaking
  72 FR 12244 03/15/2007
72 FR 26443 05/09/2007
Yes
2
IC Title Form No. Form Name
Work History Report SSA-3369-BK Work History Report
Work History Report (EDCS)
  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 449,500 871,000 0 0 -421,500 0
Annual Time Burden (Hours) 449,500 871,000 0 0 -421,500 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
Yes
Using Information Technology
The change in the SSA-3369 public burden hours since the last OMB Notice of Action (2004 OMB Approval) is based on data estimates that fewer respondents are using the paper form and the availability of EDCS 3369 data. Data collection for the EDCS 3369 didn’t begin until 2004. The SSA-3369 public reporting burden hours in Item #12 now includes the EDCS 3369 data. There have been no program changes and only minor revisions to this form since the last OMB approval on 06/10/04.
$18,158,700
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Elizabeth Davidson 411-965-0454 liz.davidson@ssa.gov
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
07/25/2007