Child-Care Dropout Questionnaire

Forms and Documents

Document Name	Status
Form SSA-4162 Child-Care Dropout Questionnaire Form	Modified
SSA--4162 Current Version.pdf Justification for No Material/Nonsubstantive Change	2015-05-14

IC Document Collections

IC ID	Document Title	Status
9367	Child-Care Dropout Questionnaire Form	Modified

ICR Details

OMB Control No: 0960-0474	ICR Reference No: 201505-0960-012
Status: Historical Active	Previous ICR Reference No: 201303-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Child-Care Dropout Questionnaire
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: 05/15/2015
	Date Received in OIRA: 05/14/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2016	07/31/2016	07/31/2016
Responses	2,000	0	2,000
Time Burden (Hours)	167	0	167
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the information from on Form SSA-4162 to determine if an individual qualifies for a child care exclusion in computing the individual's disability benefit amount. Respondents are applicants for disability benefits. Non-substantive change request - We are adding a fillable PDF version of the collection instrument Form SSA-4162, Child Care Dropout Questionnaire.

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Authorizing Statute(s): US Code: 42 USC 415 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:
	78 FR 19794	04/02/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 33142	06/03/2013
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
Child-Care Dropout Questionnaire	SSA-4162, SSA-4162	Child-Care Dropout Questionnaire ,   Child Care Dropout Questionnaire

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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	2,000	2,000	0	0	0	0
Annual Time Burden (Hours)	167	167	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: $3,080

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: 05/14/2015

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