OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)

ICR 201004-0960-001 · OMB 0960-0542 · Historical Active

Forms and Documents
Document
Name
Status
Form
 Modified
Supporting Statement A
2010-08-05
Supplementary Document
2010-08-04
IC Document Collections
IC ID
Document
Title
Status
9455 Modified
ICR Details
0960-0542 201004-0960-001
Historical Active 200706-0960-001
SSA
Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)
Revision of a currently approved collection   No
Regular
Approved without change 09/15/2010
Retrieve Notice of Action (NOA) 08/05/2010
  Inventory as of this Action Requested Previously Approved
09/30/2013 36 Months From Approved 11/30/2010
500,000 0 550,000
166,667 0 183,333
0 0 0
Forms SSA-3375-BK through SSA-3379-BK request information from the child’s parent about the child’s day-to-day functioning. The five different versions of the form contain questions about functioning appropriate to a particular age group; thus, respondents use only one version for each particular child. The adjudicative team (disability examiners and medical/psychological consultants) of state disability determination services (DDSs) collects the information on the appropriate version of this form (in conjunction with medical and other evidence) to form a complete picture of the child’s ability to function and of his/her impairment-related limitations. When this profile of the child’s functioning is complete, the adjudicative team determines whether or not the child’s impairment(s) results in marked and severe functional limitations, and, therefore, whether or not the child is disabled. The respondents are parents and/or guardians of child applicants for Supplemental Security Income (SSI) payments.
US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 1382c Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
  
None
Not associated with rulemaking
  75 FR 27036 05/13/2010
75 FR 45190 08/02/2010
No
  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 500,000 550,000 0 0 -50,000 0
Annual Time Burden (Hours) 166,667 183,333 0 0 -16,666 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
We based the change in the number of respondents on data in the 2009 SSI Report to Congress.
$7,155,500
No
No
No
Uncollected
No
Uncollected
Faye Lipsky 410 965-8783 faye.lipsky@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.
08/05/2010