Medical Report (General)

Forms and Documents

Document Name	Status
Form SSA-3826 Medical Report (General) Form	Modified
addendum.doc Supplementary Document	2010-09-07
Supporting Statement -0052 (revised).doc Supporting Statement A	2010-09-07

IC Document Collections

IC ID	Document Title	Status
8971	Medical Report (General) Form	Modified

ICR Details

OMB Control No: 0960-0052	ICR Reference No: 201005-0960-005
Status: Historical Active	Previous ICR Reference No: 200708-0960-011
Agency/Subagency: SSA	Agency Tracking No:
Title: Medical Report (General)
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: 10/28/2010
	Date Received in OIRA: 09/14/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	36 Months From Approved	12/31/2010
Responses	150,000	0	150,000
Time Burden (Hours)	75,000	0	75,000
Cost Burden (Dollars)	0	0	0

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Abstract: SSA, through its agents, the disability determination services (DDSs), uses form SSA 3826-F4 to make accurate determinations in disability claims cases. The information collected on the SSA-3826-F4 is used in determining the claimant’s physical and mental status prior to making a disability determination, and to document the disability claims folder with the medical evidence. Thus, it provides disability adjudicators and reviewers with a narrative record and history of the alleged disability and with the objective medical findings necessary to make a disability determination. SSA uses the medical evidence provided on this form in making a determination of whether an individual’s impairment meets the severity and duration requirements required for disability benefits. The respondents are members of the medical community including individual physicians, hospital doctors, medical records librarians, and other medical sources.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 42 USC 405 Name of Law: Social Security Act
  

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:
	75 FR 35512	06/22/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 54211	09/03/2010
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
Medical Report (General)	SSA-3826	Medical Report (General)

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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	150,000	150,000	0	0	0	0
Annual Time Burden (Hours)	75,000	75,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $3,384,000

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 09/14/2010

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