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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0960-0578
ICR Reference No:
200702-0960-002
Status:
Historical Active
Previous ICR Reference No:
200406-0960-004
Agency/Subagency:
SSA
Agency Tracking No:
Title:
Work History Report
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
12/07/2007
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/25/2007
Terms of Clearance:
This ICR is approved on the understanding that SSA will, within the next 36 months and prior to renewal of this ICR, convene two focus groups of (a) disability adjudicators and (b) SSA claimants/benes. Anecdotal evidence suggests that claimants have difficulty with the parts of this form that ask them to break down their daily work activities by the hour (i.e. "in this job, how many total hours each day did you crouch, kneel, stoop," etc.). In turn, SSA adjudicators may need to follow-up with claimants to get the information they need because they could not obtain it through the form. The purpose of these focus groups will be to evaluate the utility of this question and to assess the extent to which utility could be improved. SSA agrees to ask adjudicators questions such as "how ofen is the information provided on this form incomplete, unreliable, or otherwise inadequate, requiring you to follow-up with the claimant to get the information required?" Questions to be asked of claimants include questions like "how easy or difficult do you find this question to answer?"
Inventory as of this Action
Requested
Previously Approved
Expiration Date
12/31/2010
36 Months From Approved
12/31/2007
Responses
449,500
0
871,000
Time Burden (Hours)
449,500
0
871,000
Cost Burden (Dollars)
0
0
0
Abstract:
The SSA-3369-BK is used to document an applicant's work history. The information is used by Disability Determination Services (DDS) to make a decision about the alleged disability. The respondents are applicants for disability benefits.
Authorizing Statute(s):
US Code:
42 USC 423
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
72 FR 12244
03/15/2007
30-day Notice:
Federal Register Citation:
Citation Date:
72 FR 26443
05/09/2007
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Work History Report
SSA-3369-BK
Work History Report
Work History Report (EDCS)
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
449,500
871,000
0
0
-421,500
0
Annual Time Burden (Hours)
449,500
871,000
0
0
-421,500
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
Yes
Burden Reduction Due to:
Using Information Technology
Short Statement:
The change in the SSA-3369 public burden hours since the last OMB Notice of Action (2004 OMB Approval) is based on data estimates that fewer respondents are using the paper form and the availability of EDCS 3369 data. Data collection for the EDCS 3369 didnt begin until 2004. The SSA-3369 public reporting burden hours in Item #12 now includes the EDCS 3369 data. There have been no program changes and only minor revisions to this form since the last OMB approval on 06/10/04.
Annual Cost to Federal Government:
$18,158,700
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]?
Uncollected
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Uncollected
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
Uncollected
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Elizabeth Davidson 411-965-0454 liz.davidson@ssa.gov
Common Form ICR:
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:
(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:
07/25/2007