Function Report - Adult

Forms and Documents

Document Name	Status
Form SSA-3373 Function Report - Adult Form and Instruction	Modified
Justification for Non-Substantive Changes - 0681.docx Justification for No Material/Nonsubstantive Change	2013-11-08

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: 201311-0960-003
Status: Historical Active	Previous ICR Reference No: 201207-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Function Report - Adult
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/26/2013
	Date Received in OIRA: 11/12/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2015	11/30/2015	11/30/2015
Responses	4,221,656	0	4,221,656
Time Burden (Hours)	4,292,017	0	4,292,017
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses Form SSA-3373-BK 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. This Non-Substantive Change Request adds a new fillable PDF version of the form which SSA will use to replace the current PDF version, allowing respondents to complete the form electronically prior to printing and submitting it.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   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:
	77 FR 40401	07/09/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 58903	09/24/2012
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, SSA-3373	Function Report -- Adult ,   Function Report - Adult

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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	4,221,656	4,221,656	0	0	0	0
Annual Time Burden (Hours)	4,292,017	4,292,017	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: $39,003,879

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: 11/12/2013

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