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Federal forms, ICRs, and supporting documents

Information Collection Request

Certification of Low Birth Weight for SSI Eligibility 20 CFR, 416.931, 416.926a(m)(7) and (8) and 416.924

ICR 200603-0960-001 · OMB 0960-0720 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
9777 Certification of Low Birth Weight for SSI Eligibility 20 CFR, 416.931, 416.926a(m)(7) and (8) and 416.924 Form Migrated
ICR Details
0960-0720 200603-0960-001
Historical Active
SSA
Certification of Low Birth Weight for SSI Eligibility 20 CFR, 416.931, 416.926a(m)(7) and (8) and 416.924
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 05/19/2006
Retrieve Notice of Action (NOA) 03/06/2006
SSA agrees to add a sentence to the bottom of the form stating that respondents should return the form to the local field office shown at the top of the page.
  Inventory as of this Action Requested Previously Approved
05/31/2009 05/31/2009
24,000 0 0
6,000 0 0
0 0 0
Form SSA-3830 is designed to assist hospitals and claimants who file on behalf of low birth weight infants to provide SSA and Disability Determinationn Services with medical information to determine disability. The collection is used as a protective filing statement and the medical information for making presumptive disability findings which allows expedited payment to eligible claimants. The respondents are hospitals and claimants.
None
None
No
1
IC Title Form No. Form Name
Certification of Low Birth Weight for SSI Eligibility 20 CFR, 416.931, 416.926a(m)(7) and (8) and 416.924 SSA-3830
  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 24,000 0 0 24,000 0 0
Annual Time Burden (Hours) 6,000 0 0 6,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  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.
03/06/2006