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)
Revision of a currently approved collection
No
Regular
12/13/2024
Requested
Previously Approved
36 Months From Approved
12/31/2024
524,762
579,000
795,890
221,950
0
0
As part of SSA’s disability determination process, we use Forms SSA-3375-BK through SSA-3379-BK to request information from a child’s parent or guardian for children applying for Supplemental Security Income (SSI). The five different versions of the form contain questions about the child’s day-to-day functioning appropriate to a particular age group; thus, respondents use only one version of the form for each child. The adjudicative team (disability examiners and medical or psychological consultants) of State disability determination services offices collect the information on the appropriate version of this form (in conjunction with medical and other evidence) to form a complete picture of the children’s ability to function and their impairment-related limitations. The adjudicative team uses the completed profile to determine: (1) if each child’s impairment(s) results in marked and severe functional limitations; and (2) whether each child is disabled. The respondents are parents and guardians of child applicants for SSI.
US Code:
42 USC 1382c
Name of Law: Social Security Act
US Code:
42 USC 423
Name of Law: Social Security Act
US Code:
42 USC 1383
Name of Law: Social Security Act
When we last cleared this information collection in 2021, the burden was 193,000 hours. However, we are currently reporting a burden of 174,921 hours. This change stems from a decrease in the number of responses from 579,000 to 524,762. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data.
As mentioned above, SSA is unable to breakdown the method by which the respondents complete the (whether it was completed electronically via the Intranet; through an in-office or telephone appointment; or if it was a paper version submitted to the FO or DDS upon completion, which was then scanned into the electronic file. Therefore, unlike the information collection in 2021, we are not able to precisely predict how many respondents physically traveled to the FO. At the prior information collection for this form (2021), we determined that approximately 10% of respondents visited the FO to submit a paper version of the form, relevant to the child’s age. Although we cannot provide exact data on this scope, we predict that 15% of respondents spent time traveling to/from the FO, which indicates 39,358 hours of travel time.
* Note: The total burden reflected in ROCIS is 795,890, while the burden cited in #12 of the Supporting Statement is 174,921. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a 30-minute, one-way, drive burden + learning costs. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.
$5,793,080
No
Yes
Yes
No
No
No
No
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.
Form SSA-3375-BK Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview
Supporting Statement - 0542 (Final).docx
Function Report - Child (SSA-3375, SSA-3376, SSA-3377, SSA-3378, SSA-3379) - Phone Interview