2017-00500. Agency Information Collection Activities: Proposed Request and Comment Request

The Social Security Administration (SSA) publishes a list of information collection packages requiring clearance by the Office of Management and Budget (OMB) in compliance with Public Law 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. This notice includes revisions of OMB-approved information collections.

SSA is soliciting comments on the accuracy of the agency's burden estimate; the need for the information; its practical utility; ways to enhance its quality, utility, and clarity; and ways to minimize burden on respondents, including the use of automated collection techniques or other forms of information technology. Mail, email, or fax your comments and recommendations on the information collection(s) to the OMB Desk Officer and SSA Reports Clearance Officer at the following addresses or fax numbers.

(OMB), Office of Management and Budget, Attn: Desk Officer for SSA, Fax: [phone], Email address: [e-mail]

(SSA), Social Security Administration, OLCA, Attn: Reports Clearance Director, 3100 West High Rise, 6401 Security Blvd., Baltimore, MD 21235, Fax: [phone], Email address: [e-mail]

Or you may submit your comments online through www.regulations.gov, referencing Docket ID Number [SSA-2017-0001].

I. The information collections below are pending at SSA. SSA will submit them to OMB within 60 days from the date of this notice. To be sure we consider your comments, we must receive them no later than March 13, 2017. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. State Mental Institution Policy Review Booklet—20 CFR 404.2035, 404.2065, 416.635, & 416.665—0960-0110. SSA uses Form SSA-9584-BK: (1) To determine if the policies and practices of a state mental institution acting as a representative payee for SSA beneficiaries conform to SSA's regulations in the use of benefits; (2) to confirm institutions are performing other duties and responsibilities required of representative payees; and (3) as the basis for conducting onsite reviews of the institutions and preparing subsequent reports of findings. The respondents are state mental institutions serving as representative payees for Social Security beneficiaries and Supplemental Security Income (SSI) recipients.

Type of Request: Revision of an OMB-approved information collection.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-9584-BK	69	1	60	69

2. Statement of Death by Funeral Director—20 CFR 404.715 and 404.720—0960-0142. When an SSA-insured worker dies, the funeral director or funeral home responsible for the worker's burial or cremation completes Form SSA-721 and sends it to SSA. SSA uses this information for three purposes: (1) To establish proof of death for the insured worker; (2) to determine if the insured individual was receiving any pre-death benefits SSA needs to terminate; and (3) to ascertain which surviving family member is eligible for the lump-sum death payment or for other death benefits. The respondents are funeral directors who handled death arrangements for the insured individuals.

Type of Request: Revision of an OMB-approved information collection.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-721	703,638	1	4	46,909

3. Employee Identification Statement—20 CFR 404.702—0960-0473. When two or more individuals report earnings under the same Social Security Number (SSN), SSA collects information on Form SSA-4156 to credit the earnings to the correct individual and SSN. We send the SSA-4156 to the employer to: (1) Identify the employees involved; (2) resolve the discrepancy; and (3) credit the earnings to the correct SSN. The respondents are employers involved in erroneous wage reporting for an employee.

Type of Request: Revision of an OMB-approved information collection.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-4156	4,750	1	10	792

4. Employee Work Activity Questionnaire—20 CFR 404.1574, 404.1592—0960-0483. SSI recipients qualify for payments when a verified physical or mental impairment prevents them from working. If disability claimants attempt to return to work after receiving payments, but are unable to continue working, they submit the SSA-3033, Employee Work Activity Questionnaire, so SSA can evaluate their work attempt. SSA also uses this form to evaluate unsuccessful subsidy work and determine applicants' continuing eligibility for disability payments. The respondents are employers of Social Security disability beneficiaries and SSI recipients who unsuccessfully attempted to return to work.

Type of Request: Revision of an OMB-approved information collection.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-3033-BK	15,000	1	15	3,750

5. Epidemiological Research Report—20 CFR 401.165—0960-0701. Section 1106(d) of the Social Security Act directs the Social Security Administration (SSA) to provide support to researchers involved in epidemiological or similar research. Specifically, when, in consultation with the Department of Health and Human Services, we determine a study contributes to a national health interest, SSA furnishes information to determine if a study subject appears in SSA administrative records as alive or deceased (vital status). SSA charges a small fee per request for providing this information. SSA's Internet application questions solicit the information SSA needs to provide the data and to collect the fees. The respondents are qualified health and scientific researchers who apply to receive vital status information about individuals from Social Security administrative data records.

Type of Request: Revision of an OMB-approved information collection.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
State & Local Government—Interent Application	15	1	120	30
Private Entities—Internet Application	10	1	120	20
Totals	25			50

Cost Burden:

• Average annual cost per respondent (based on SSA data): $3,500.
• Total estimated annual cost burden: $87,500.

6.Request for Medical Treatment in an SSA Employee Health Facility: Patient Self-Administered or Staff Administered Care—0960-0772. SSA operates onsite Employee Health Clinics (EHC) in eight different States. These clinics provide health care for all SSA employees including treatments of personal medical conditions when authorized through a physician. Form SSA-5072 is the employee's personal physician's order form. The information we collect on Form SSA-5072 gives the nurses the guidance they need by law to perform certain medical procedures and to administer prescription medications such as allergy immunotherapy. In addition, the form allows the medical officer to determine whether they can administer treatment safely and appropriately in the SSA EHCs. Respondents are physicians of SSA employees who need to have medical treatment in an SSA EHC.

Type of Request: Revision of an OMB-approved information collection.

Modality of collection	Number of respondents	Frequency of response	Number of responses	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-5072 Annually	25	1	25	5	2
SSA-5072 Bi-Annually	75	2	150	5	13
Totals	100				15

II. SSA submitted the information collections below to OMB for clearance. Your comments regarding the information collections would be most useful if OMB and SSA receive them 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than February 13, 2017. Individuals can obtain copies of the OMB clearance package by writing to [e-mail].

1. Petition to Obtain Approval of a Fee for Representing a Claimant Before the Social Security Administration—20 CFR 404.1720 and 404.1725; 20 CFR 416.1520 and 416.1525—0960-0104. A Social Security claimant's representative, whether an attorney or a non-attorney, uses Form SSA-1560-U4 to petition SSA for authorization to charge and collect a fee. A claimant may also use the form to agree or disagree with the requested fee amount or other information the representative provides on the form. The SSA official responsible for setting the fee uses the information from the form to determine a reasonable fee amount representatives may charge for their services. The respondents are attorneys and non-attorneys who represent Social Security claimants.

Type of Request: Revision of an OMB-approved information collection.

Modality of collection	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-1560-U4	44,365	1	30	22,183

2. Requests for Self-Employment Information, Employee Information, Employer Information—20 CFR 422.120—0960-0508. When SSA cannot identify Form W-2 wage data for an individual, we place the data in an earnings suspense file and contact the individual (and in certain instances the employer) to obtain the correct information. If the respondent furnishes the name and SSN information that agrees with SSA's records, or provides information that resolves the discrepancy, SSA adds the reported earnings to the respondent's Social Security record. We use Forms SSA-L2765, SSA-L3365, and SSA-L4002 for this purpose. The respondents are self-employed individuals and employees whose name and SSN information do not agree with their employer's and SSA's records.

Type of Request: Revision of an OMB approved information collection.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-L2765	12,321	1	10	2,054
SSA-L3365	179,749	1	10	29,958
SSA-L4002	121,679	1	10	20,280
Totals	313,749			52,292

Dated: January 9, 2017.

Naomi R. Sipple,

Reports Clearance Officer, Social Security Administration.