OMB control number

Certification of Low Birth Weight for SSI Eligibility

OMB 0960-0720 · SSA.

OMB 0960-0720

Hospitals and claimants use Form SSA-3830 to provide medical information to local field offices (FOs) and Disability Determinations Services (DDSs) on behalf of infants with low birth weight. FOs use the form as a protective filing statement, and the medical information to make presumptive disability findings, which allow expedited payment to eligible claimants. DDSs use the medical information from the SSA-3830 to determine disability and continuing disability. The respondents are hospitals and claimants who have information identifying low birth weight babies and their medical conditions.

The latest form for Certification of Low Birth Weight for SSI Eligibility expires 2026-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-3830 Certification of Low Birth Weight for SSI Eligibility Form
Addendum - 0720.docx Supplementary Document
Supporting Statement - 0720.docx Supporting Statement A
Certification of Low Birth Weight for SSI Eligibility Form

All Historical Document Collections

202010-0960-007 Approved with change	Revision of a currently approved collection	2021-01-28
201709-0960-001 Approved without change	Revision of a currently approved collection	2017-12-29
201409-0960-004 Approved without change	Revision of a currently approved collection	2014-12-09
201112-0960-001 Approved without change	Revision of a currently approved collection	2012-03-26
200811-0960-009 Approved without change	Revision of a currently approved collection	2009-04-21
200603-0960-001 Approved with change	New collection (Request for a new OMB Control Number)	2006-03-06