View Information Collection Request (ICR) Package

OMB Control No: 0960-0542	ICR Reference No: 202407-0960-008
Status: Active	Previous ICR Reference No: 201904-0960-016
Agency/Subagency: SSA	Agency Tracking No:
Title: 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)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/04/2025
	Date Received in OIRA: 12/13/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2028	36 Months From Approved	03/31/2025
Responses	524,762	0	579,000
Time Burden (Hours)	795,890	0	221,950
Cost Burden (Dollars)	0	0	0

Abstract: 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.

Authorizing Statute(s): 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

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:
	89 FR 74351	09/12/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 97155	12/06/2024
Did the Agency receive public comments on this ICR? No

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion	Change Due to Adjustment in Estimate
Annual Number of Responses	524,762	579,000	-521,100	466,862
Annual Time Burden (Hours)	795,890	221,950	-173,700	747,640
Annual Cost Burden (Dollars)	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: 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.

Annual Cost to Federal Government: $5,793,080

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

View ICR - OIRA Conclusion