View Information Collection Request (ICR) Package
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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:
202009-0960-011
Status:
Active
Previous ICR Reference No:
201701-0960-017
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:
08/12/2024
Retrieve Notice of Action (NOA)
Date Received in OIRA:
12/09/2020
Terms of Clearance:
The agency made substantial modifications to the Supporting Statement A to provide greater clarity regarding the operation of the information collection and increased the burden estimate. The agency will continue to engage with OMB regarding further improvements to the questions posed on the information collection in light of feedback received during the 0960-AI83 rulemaking.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
08/31/2027
36 Months From Approved
08/31/2024
Responses
1,591,949
0
1,591,949
Time Burden (Hours)
3,024,703
0
1,591,949
Cost Burden (Dollars)
0
0
0
Abstract:
SSA asks individuals applying for disability about work they performed in the past. Applicants use Form SSA-3369, Work History Report, to provide SSA with detailed information about applicant’s jobs held prior to becoming unable to work. State Disability Determination Services evaluate the information together with medical evidence, to determine eligibility for disability payments. The respondents are disability applicants and third parties assisting applicants.
Authorizing Statute(s):
US Code:
42 USC 423
Name of Law: Disability Insurance Benefits
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:
85 FR 63630
10/08/2020
30-day Notice:
Federal Register Citation:
Citation Date:
85 FR 79064
12/08/2020
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Work History Report
SSA-3369
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
1,591,949
1,591,949
0
0
0
0
Annual Time Burden (Hours)
3,024,703
1,591,949
0
0
1,432,754
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:
There are no changes to the public reporting burden. Note: The total burden reflected in ROCIS is 3,024,703, while the burden cited in #12 of the Supporting Statement is 1,591,949. 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. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.
Annual Cost to Federal Government:
$4,185,990
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
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?
No
Agency Contact:
Faye Lipsky 410 965-8783 faye.lipsky@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:
12/09/2020
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