2011-27222. 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 (Pub. L.) 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. This notice includes revisions to 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, e-mail, 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]. E-mail address: [e-mail].

(SSA), Social Security Administration, DCBFM, Attn: Reports Clearance Officer, 107 Altmeyer Building, 6401 Security Blvd., Baltimore, MD 21235. Fax No.: 410-966-2830. E-mail address: [e-mail].

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 December 19, 2011. Individuals can obtain copies of the collection instruments by calling the SSA Reports Clearance Officer at 410-965-8783 or by writing to the above e-mail address.

1. Medical Report on Adult with Allegation of Human Immunodeficiency Virus Infection; Medical Report on Child with Allegation of Human Immunodeficiency Virus Infection—20 CFR 416.933-20; CFR 416.934 —0960-0500. SSA uses Forms SSA-4814-F5 and SSA-4815-F6 to collect information necessary to determine if an individual with human immunodeficiency virus infection, who is applying for Supplemental Security Income (SSI) disability benefits, meets the requirements for presumptive disability payments. The respondents are the medical sources of the applicants for SSI disability payments.

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

Collection instrument	Number of responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-4814-F5	46,200	1	10	7,700
SSA-4815-F6	12,900	1	10	2,150
Totals	59,100			9,850

2. Supplement to Claim of Person Outside the United States—20 CFR 404.463, 20 CFR 422.505(b) and 20 CFR 407.27(c)—0960-0051. Claimants or beneficiaries (both United States (U.S.) citizens and aliens entitled to benefits) living outside the U.S. complete Form SSA-21 as a supplement to an application for benefits. SSA collects the information to determine eligibility for U.S. Social Security benefits for those months a beneficiary or claimant is outside the U.S., and to determine if tax withholding applies. In addition, SSA uses the information to terminate Supplemental Medical Insurance coverage for recipients who request it, because they are or will be out of the U.S. The respondents are individuals entitled to Social Security benefits who are, will be, or have been residing outside the U.S. for three months or longer.

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

Collection instrument	Number of responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-21 (non-residents)	36,874	1	5	3,073
SSA-21 (U.S. citizens and residents)	1,941	1	15	485
Totals	38,815			3,559

3. Credit Card Payment Form—0960-0648. SSA uses form SSA-1414 to process: (1) Credit card payments from former employees and vendors with outstanding debts to the agency; (2) advance payments for reimbursable agreements; and (3) credit card payments for all Freedom of Information Act (FOIA) requests requiring payment. The respondents are former employees and vendors who have outstanding debts to the agency, entities who have reimbursable agreements with SSA, and individuals who request information through FOIA.

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

Collection instrument	Number of responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-1414	6,000	1	2	200

4. Benefit Offset National Demonstration—0960-0785. In an effort to produce strong evidence about the effectiveness of potential solutions that would improve the historically very low rate of return to work among SSDI beneficiaries, SSA is currently conducting the Benefit Offset National Demonstration (BOND) project. The demonstration project will evaluate the result of policy changes and services on the Social Security Disability Insurance (SSDI) program.

Under current law, Social Security beneficiaries lose their SSDI benefit if they have earnings and/or work activity above the threshold of substantial gainful activity (SGA) after completing the trial work period and two-month grace period. The benefit-offset component of this demonstration reduces benefits by $1 for each $2 in earnings above the BOND threshold, resulting in a gradual reduction in benefits as earnings increase.

BOND tests a benefit offset alone and in conjunction with enhanced work incentives counseling. The central research questions include:

• What is the effect of the benefit offset alone on employment and other outcomes?
• What is the effect of the benefit offset in combination with enhanced work incentives counseling on employment and other outcomes?

The public survey data collections for BOND have four components—an impact study, a cost-benefit analysis, a participation analysis, and a process study. The data collections are a primary source for data to measure the effects of a more generous benefit offset and the provision of enhanced work incentives counseling on SSDI beneficiaries' work efforts and earnings. Ultimately, these data will benefit researchers, policy analysts, policy makers, and the United States Congress in a wide range of program areas.

The effects of BOND on the well-being of SSDI beneficiaries could manifest themselves in many dimensions and could be relevant to an array of other public programs. This project offers the opportunity to obtain reliable measures of these effects based upon a nationally representative sample. The long-term indirect benefits of this research are likely to be substantial. Respondents are SSDI beneficiaries and concurrent SSDI and SSI recipients who we randomly assign to the study (Stage 1), and SSDI beneficiaries who agree to participate in the study (Stage 2).

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

Survey	Number of respondents	Frequency of response	Number of responses	Average burden per response (minutes)	Estimated total annual burden (hours)
Participation Agreement	12,600	1	12,600	20	4200
Baseline Survey	12,600	1	12,600	41	8,610
Interim Survey	10,080	1	10,080	29	4,872
Stage 1 36-month Survey	8,000	1	8,000	49	6,533
Stage 2 36-month Survey	10,080	1	10,080	60	10,080
Enhanced Work Incentives Assessment	3,000	1	3,000	35	1,750
Key Informant Interviews	100	7	700	60	700
Stage 2 Participant Focus Groups	600	1	600	90	900
Stage 1 First Contact Letter Survey	500	1	500	3	25
Totals	57,560		58,160		37,670

II. SSA submitted the information collection below to OMB for clearance. Your comments regarding the information collection would be most useful if OMB and SSA receive them within 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than November 21, 2011. Individuals can obtain copies of the OMB clearance package by calling the SSA Reports Clearance Officer at 410-965-8783 or by writing to the above e-mail address.

Claimant's Work Background—20 CFR 404.1565(b) and 20 CFR 416.965(b)—0960-0300. Sections 205(a) and 1631(e) of the Social Security Act provide the Commissioner of Social Security with the authority to establish procedures for determining if a claimant is entitled to disability benefits. The administrative law judge (ALJ) may ask individuals to provide background information on Form HA-4633 about work they performed in the past 15 years. The ALJ uses the information to assess an individual's disability based on an updated summary of the individual's relevant work history. The HA-4633 becomes part of the documentary evidence of record. The respondents are claimants for disability benefits under title II or title XVI who requested a hearing before an ALJ.

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

Collection instrument	Number of responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
HA-4633	200,000	1	15	50,000

Dated: October 17, 2011.

Faye Lipsky,

Reports Clearance Officer, Center for Reports Clearance, Social Security Administration.