E8-10. Agency Information Collection Activities: Proposed Request and Comment Request

The Social Security Administration (SSA) publishes a list of information collection packages that will require 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. The information collection packages that may be included in this notice are for new information collections, approval of existing information collections, revisions to OMB-approved information collections and extensions (no change) 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 on ways to minimize the burden on respondents, including the use of automated collection techniques or other forms of information technology. Written comments and recommendations regarding the information collection(s) should be submitted to the OMB Desk Officer and the SSA Reports Clearance Officer. The information can be mailed, faxed or emailed to the individuals at the addresses and fax numbers listed below:

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

(SSA), Social Security Administration, DCBFM, Attn: Reports Clearance Officer, 1333 Annex Building, 6401 Security Blvd., Baltimore, MD 21235, Fax: [phone], E-mail address: [e-mail].

I. The information collections listed below are pending at SSA and will be submitted to OMB within 60 days from the date of this notice. Therefore, your comments should be submitted to SSA within 60 days from the date of this publication. You can obtain copies of the collection instruments by calling the SSA Reports Clearance Officer at 410-965-0454 or by writing to the address listed above.

1. Function Report—Adult—Third Party—20 CFR 404.1512, 416.912—0960-0635. The information collected on the SSA-3380-BK is needed to make determinations on Supplemental Security Income (SSI) and Social Security disability (SSDI) claims. This information is necessary for case development and adjudication, and is used by State Disability Determination Services (DDS) evaluators as an evidentiary source used in the disability evaluation process. The respondents are third parties familiar with the functional limitations (or lack thereof) of claimants who apply for SSDI benefits and SSI payments.

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

Number of Respondents: 1,000,000.

Frequency of Response: 1.

Average Burden per Response: 60 minutes.

Estimated Annual Burden: 1,000,000 hours.

2. Function Report—Adult—20 CFR 404.1512 and 419.912—0960-0681. Form SSA-3373 is used to collect information about a disability applicant's impairment-related limitations and ability to function. It documents the types of information specified in SSA regulations and provides disability interviewers with a convenient means to record information about how the claimant's condition affects his or her ability to function. This information, together with medical evidence, forms the evidentiary basis upon which the initial disability process is founded. The respondents are SSDI and SSI applicants.

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

Number of Respondents: 4,005,367.

Frequency of Response: 1.

Average Burden per Response: 60 minutes.

Estimated Annual Burden: 4,005,367 hours.

3. Information Collections conducted by State DDS's on Behalf of SSA—20 CFR, subpart P, 404.1503a, 404.1512, 404.1513, 404.1514 404.1517, 404.1519; 20 CFR subpart Q, 404.1613, 404.1614, 404.1624; 20 CFR subpart I, 416.903a, 416.912, 416.913, 416.914, 416.917, 416.919 and 20 CFR subpart J, 416.1013, 416.1024, 416.1014—0960-0555. The State DDS's collect certain information to administer the SSDI and SSI programs. They collect information from medical sources on consultative examination (CE) medical evidence, CE credentials and Medical Evidence of Record (MER). The DDS's collect information from claimants regarding medical appointments and pain/symptoms. The respondents are medical providers, other sources of MER and disability claimants.

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

The total combined burden is 1,803,810 hours.

CE Collections

There are two collections from CE providers: (a) Medical evidence about claimants, which DDS's use to make disability determinations when the claimant's own medical sources cannot or will not provide the required information; and (b) when CE providers offer proof of their credentials.

(a) Medical Evidence from CE Providers

	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
Paper Submissions	1,215,000	1	30	607,500
Electronic Records Express (ERE) Submissions	285,000	1	15	71,250
Totals	1,500,000	—	—	678,750

CE Credentials

	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
Paper Submission	3,000	1	20	1,000

There are two CE claimant collections: (a) CE claimant completion of a response form in which claimants indicate if they intend to keep their CE appointment; and (b) CE claimant completion of a form indicating whether they want a copy of the CE report to be sent to their doctor.

(a) Claimants re Appointment Letter

	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
Paper Submission	750,000	1	5	62,500

(b) Claimants re Report to Medical Provider

	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
Paper Submission	1,500,000	1	5	125,000

MER Collections

The DDS's collect MER information from the claimant's own medical sources to determine a claimant's physical and/or mental status, prior to making a disability determination.

	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
Paper Submissions	2,480,800	1	15	620,200
Connect Direct (CD), (electronic transfer)	218,400	1	15	54,600
ERE Submission	100,800	1	7	11,760
Total	2,800,000			686,560

Pain/Other Symptoms Information From Claimants

The DDSs use information about pain/symptoms to determine how pain/symptoms affect the claimant's ability to do work-related activities, prior to making a disability determination.

	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
Paper Submission	1,000,000	1	15	250,000

4. Social Security Number (SSN) Verification Services—20 CFR 401.45—0960-0660. Under Internal Revenue Service regulations employers are obligated to provide wage and tax data to the SSA using Form W-2 or its electronic equivalent. As part of this process the employer must furnish the employee's name and their SSN. The employee's name and SSN must match SSA's records in order for the employee's earnings to be properly posted to their Earnings Record, which is maintained by SSA.

In order to better assure that employers provide accurate employee name and SSN data that match SSA's records, SSA offers serveral cost-free methods for employers to verify the information, as follows: (1) Internet-based service, known as the Social Secuirty Number Verification Service (SSNVS), where the employer can verify if the reported names and SSNs of their employees matches SSA's records; (2) the Employee Verification Service (EVS), where employers can verify, via cartridge, diskette, paper and telephone if the reported name and SSN of their employees matches SSA's records; (3) through our National 800 Number SSA, which is introducing an automated telephone employee verification service (TNEV) that will allow callers, who have been authenicated and have a pin and password to use for this process, to verify employee's names and SSNs through the telephone system.

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

Verification system	Number of respondents	Frequency of response	Number of responses	Average burden per response (minutes)	Total annual burden (hours)
EVS	50,000	16	800,000	10	133,333
SSNVS	200,000	60	12,000,000	5	1,000,000
TNEV	5,798	60	347,880	9	52,182
Total	255,798		2,347,880		1,185,515

5. Agreement to Sell Property—20 CFR 416.1240-1245—0960-0127. Individuals or couples who are otherwise eligible for SSI benefits but whose resources exceed the allowable limit may receive conditional payments if they agree to dispose of the excess non-liquid resources and make repayment. Form SSA-8060 is used to document this agreement and to ensure that the individuals understand their obligations. Respondents are applicants and recipients of SSI benefits who will be disposing of excess non-liquid resources.

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

Number of Respondents: 20,000.

Frequency of Response: 1.

Average Burden per Response: 10 minutes.

Estimated Annual Burden: 3,333 hours.

6. Listing of Impairments—Part 404, Subpart P, Appendix I and II—0960-0642.

Background

The Listing of Impairments (the listings), part 404, subpart P, appendix I and II, describes for each of the major body systems, impairments which are severe enough to prevent a person from doing any gainful activity. As part of the listings, we provide a preface which identifies specific requirements that affect the body system, such as documentation requirements and other factors which must be considered when evaluating impairments within that body system. These can include requirements which include medical and other evidence. This clearance request covers sections in parts A and B.

The Information Collection

The medical evidence documentation described in the listings is used by State DDS's to assess the alleged disability. The information, together with other evidence, is used to determine if an individual claiming disability benefits has an impairment that meets severity and duration requirements. The respondents are disability applicants and other sources of evidence. The public reporting burden is accounted for in the Information Collection Requests (ICR) for the various forms that the public uses to submit the information to SSA. Consequently, we are reporting no burden for this regulation aside from a 1-hour placeholder burden.

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

7. Reporting Events—SSI—20 CFR 416.701-.732—0960-0128. The Social Security Act and regulations requires SSA to collection information to determine eligibility for SSI payments and to determine the correct payment amount. SSA periodically requests information from recipients to reevaluate their continuing SSI eligibility and payment amount using form SSA-8150-EV. Form SSA-8150-EV informs recipients of the information that needs to be reported to SSA in order to retain their benefits. Form SSA-8150-EV provides recipients with a means of reporting changes in their circumstances in writing. SSA uses the reported changes to determine SSI eligibility and correct payment amounts.

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

Number of Respondents: 27,320.

Frequency of Response: 1.

Average Burden per Response: 5 minutes.

Estimated Annual Burden: 2,277 hours.

II. The information collections listed below have been submitted to OMB for clearance. Your comments on the information collections would be most useful if received by OMB and SSA within 30 days from the date of this publication. You can obtain a copy of the OMB clearance packages by calling the SSA Reports Clearance Officer at 410-965-0454, or by writing to the address listed above.

1. Advanced Notice of Termination of Child's Benefits & Student's Statement Regarding School Attendance—20 CFR 404.350-404.352, 404.367-404.368—0960-0105. The information collected on Forms SSA-1372-BK and SSA-1372-BK-FC is needed to determine whether children of an insured worker are eligible for student benefits. The respondents are student claimants for Social Security benefits, their respective schools and, in some cases, their representative payees.

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

SSA-1372-BK:

Type of respondent	Number of respondents	Frequency of response	Average burden per response (minutes)	Total annual burden (hours)
Individuals/Households	99,850	1	11	18,306
State/Local/Tribal Government	99,850	1	11	18,306
Totals	199,700			36,612

SSA-1372-BK-FC:

Type of respondent	Number of respondents	Frequency of response	Average burden per response (minutes)	Total annual burden (hours)
Individuals/Households	150	1	11	27
State/Local/Tribal Government	150	1	11	27
Totals	300			54

Correction Notice: In the First Federal Register Notice, we inadvertently labeled this ICR as an extension instead of a revision.

2. Authorization to Disclose Information to SSA—20 CFR 404.1512 & 20 CFR 416.912—0960-0623. SSA must obtain sufficient medical evidence to make eligibility determinations for SSDI benefits and SSI payments. For SSA to obtain medical evidence, an applicant must authorize his or her medical source(s) to release the information to SSA. The applicant may use one of the forms SSA-827, SSA-827-OP1 or SSA-827-OP2 to provide consent for the release of information. Generally, the State DDS completes the form(s) based on information provided by the applicant, and sends the form(s) to the designated medical source(s).

Type of Request: Revision of a currently approved information collection.

Number of Respondents: 3,853,928.

Frequency of Response (Average per case): 4.

Total Annual Responses: 15,415,712.

Average Burden per Response: 13 minutes to complete all 4 forms.

Estimated Annual Burden: 835,018 hours.

3. Acknowledgement of Receipt (Notice of Hearing)—20 CFR 404.938 & 416.1438—0960-0671. The HA-504 and HA-504-OP1 are used to acknowledge receipt of the notice of hearing issued by an Administrative Law Judge (ALJ). The ALJ uses the information collected on the HA-504 and HA-504-OP1 to: (1) Prepare for the hearing as scheduled; or (2) reschedule the hearing to a different date and/or location. The respondents are applicants for Social Security benefits or SSI payments who request a hearing to appeal an unfavorable entitlement or eligibility determination.

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

Form	Number of respondents	Frequency of response (per year)	Average burden per response (minutes)	Total annual burden (hours)
HA-504	60,000	1	1	1000
HA-504-OP1	540,000	1	1	9000
Totals	600,000			10,000

Correction Notice: In the notice published on October 18, 2007 at 75 FR 59132 we inadvertently labeled this ICR as an extension. It is, in fact, a revision in order to reflect both versions of the form HA-504. Also, we are correcting the burden data from 660,000 respondents and 11,000 burden hours to 600,000 respondents and 10,000 burden hours.

4. Request for Waiver of Special Veterans Benefits (SVB) Overpayment Recovery or Change in Repayment Rate—20 CFR 408.900-408.950, 408.923(b), 408.931(b), 408.932(c), (d) and (e), 408.941(b) and 408.942—0960-0698. Title VIII allows the payment of a monthly benefit by the Commissioner of Social Security to a qualified World War II veteran who resides outside the United States. When an overpayment in SVB occurs, the beneficiary can use this form to request waiver of recovery of the overpayment or a change in the repayment rate. The SSA-2032-BK will be used to obtain the information necessary to determine whether the provisions of the Act regarding waiver of recovery of the overpayment are met. The information on the form is needed to determine a repayment rate if repayment cannot be waived. Respondents are beneficiaries who have overpayments on their Title VIII record and wish to file a claim for waiver of recovery or change in repayment rate.

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

Number of Respondents: 450.

Frequency of Response: 1.

Average Burden per Response: 120 minutes.

Total Annual Burden: 900 hours.

Correction Notice: We are correcting information published on September 20, 2007 at 72 FR 53803 and on November 5, 2007 at 72 FR 62510 to show updated burden information. We changed the number of respondents from 39 to 450 and the burden hours from 78 to 900 hours.

5. Request for Medical Treatment in an SSA Employee Health Facility: Patient Self-Administered or Staff Administered Care—0960-NEW. SSA operates Employee Health Clinics onsite in eight different states. These clinics provide health care for all SSA employees including treatment of personal medical conditions when authorized by a physician. The SSA-5072 is the employee's personal physician's order form. The information collected on the 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. Also, the information collected by the SSA-5072 allows the SSA Medical Officer to determine whether the treatment can be administered safely and appropriately in the SSA Employee Health Units. Each State has a Nurse Practice Act governing the practice of registered nurses in the State. All Nurse Practice Acts require that registered nurses administer prescription medications and certain medical treatments by following a licensed physician's orders. Form SSA-5072 provides the vehicle for the physician to provide these orders to the SSA nursing staff. Respondents are physicians of SSA employees who need to have medical treatment in the SSA Employee Health Unit.

Type of Request: Information Collection in Use without an OMB Number.

Reporting method	Number of respondents	Frequency of response	Number of responses	Average burden per response (minutes)	Estimated annual burden (hours)
Annual	25	1	25	5	2
Bi-Annual	75	2	150	5	13
Totals	100		175		15

6. Sheltered Workshop Wage Reporting—0960-NEW.

Collection Background

Section 1612(1)(C) of the Social Security Act (the Act) and 42 U.S.C. 1382a define remuneration received for services performed in a sheltered workshop as earned income for the SSI program. The amount of monthly wages determines an individual's SSI benefit amount.

Collection Description

SSA has maintained a working relationship with sheltered workshops since the inception of the SSI program. Most workshops report monthly wage totals to the local SSA office so that the client's SSI check is adjusted timely and overpayments are prevented. While participation of the workshop is strictly voluntary, they are highly motivated to report the wages because it provides a service to their clients. Sheltered Workshop reporting reduces the number of overpayments to SSI recipients. Processing these wage reports electronically reduces the cost of administering the program. SSA uses the information collected to verify and post monthly wages to the SSI recipient's record. Respondents are sheltered workshops that report monthly wages for services performed in the workshop.

Type of Request: New information collection.

Number of Respondents: 1,000.

Frequency of Response: 12.

Average Burden per Response: 15 minutes.

Estimated Annual Burden: 3,000 hours.

Correction Notice: We are updating information that was contained in the notices that were published at 72 FR 46529 on August 20, 2007 and 725 FR 62510 on November 5, 2007. We are changing the burden estimate from 5 to 15 minutes.

7. Request for Social Security Earnings Information—20 CFR 404.810 & 401.100—0960-0525. The Social Security Act provides that a wage earner, or someone authorized by a wage earner, may request Social Security earnings information from SSA using form SSA-7050. SSA uses the information collected on the form to verify that the requestor is authorized to access the earnings record and to produce the earnings statement. The respondents are wage earners and organizations and legal representatives authorized by the wage earner.

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

Number of Respondents: 60,000.

Frequency of Response: 1.

Average Burden per Response: 11 minutes.

Estimated Annual Burden: 11,000 hours.

Dated: December 31, 2007.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.