[Federal Register Volume 59, Number 194 (Friday, October 7, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-24767]
[[Page Unknown]]
[Federal Register: October 7, 1994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Social Security Administration
Agency Forms Submitted to the Office of Management and Budget for
Clearance
Normally on Fridays, the Social Security Administration publishes a
list of information collection packages that have been submitted to the
Office of Management and Budget (OMB) for clearance in compliance with
Pub. L. 96-511, The Paperwork Reduction Act. The following clearance
packages have been submitted to OMB since the last list was published
in the Federal Register on Friday, September 9, 1994. (Call Reports
Clearance Officer on (410) 965-4142 for copies of package.)
1. Disability Report and Disability Report (Short Form)--0960-0141.
The information on revised forms SSA-3368 and 3368A will be used by the
Social Security Administration to help make a disability determination.
The respondents will be individuals who file for disability benefits.
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SSA-3368 SSA-3368A
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Number of Respondents............. 2,164,000......... 100,000
Frequency of Response............. 1................. 1
Average Burden Per Response....... 30 minutes........ 10 minutes
Estimated Annual Burden........... 1,082,000 hrs..... 16,667 hours
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2. Work History Report--0960-0141. The information on revised form
SSA-3369 will be used by the Social Security Administration to record
information about a claimant's work history in order to help make a
disability determination. The respondents will be individuals who file
for disability benefits.
Number of Respondents: 1,000,000
Frequency of Response: 1
Average Burden Per Response: 30 minutes
Estimated Annual Burden: 500,000 hours
3. Pain Questionnaire-Adult--Child--0960-NEW. The information on
forms SSA-3370 and 3371 will be used by the Social Security
Administration to obtain the types of information specified in the
regulations and to provide disability interviewers (and claimants in
self-help situations) with a convenient means to record information
about the claimant's allegations of pain, how the pain affects his or
her ability to function in a work setting, or in the case of a child,
the ability to perform age-appropriate activities. The respondents will
be claimants for disability benefits.
Number of Respondents: 1,000,000 (total for both forms)
Frequency of Response: 1
Average Burden Per Response: 15 minutes
Estimated Annual Burden: 250,000 hours
4. Report of Function-Adult--0960-NEW. The information on form SSA-
3373 will be used by the Social Security Administration to record
information about how the claimant's condition affects his or her
ability to function. The respondents will be claimants for disability
benefits.
Number of Respondents: 2,264,000
Frequency of Response: 1
Average Burden Per Response: 15 minutes
Estimated Annual Burden: 566,000 hours
5. Disability Report-Child--0960-0504. The information on the
revised form SSA-3820 will be used by the Social Security
Administration to help make a disability determination in claims for
benefits. The respondents will be parents or guardians who file for
such benefits on behalf of a child.
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SSA-3820 SSA-3820A
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Number of Respondents............. 513,000........... 10,000
Frequency of Response............. 1................. 1
Average Burden Per Response....... 40 minutes........ 10 minutes
Estimated Annual Burden........... 342,000 hours..... 1,667 hours
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6. Plan for Achieving Self-Support (PASS) study form. The
information on the questionnaire will be used by the Social Security
Administration to determine the effectiveness of the Agency's
implementation, monitoring, and control of the PASS activities. The
study form will be used to obtain various PASS information from
Supplemental Security Income recipients.
Number of Respondents: 1,900
Frequency of Response: 1
Average Burden Per Response: 20 minutes
Estimated Annual Burden: 633 hours
OMB Desk Officer: Laura Oliven.
Written comments and recommendations regarding these information
collections should be sent directly to the appropriate OMB Desk Officer
designated above at the following address: Office of Management and
Budget, OIRA New Executive Office Building, Room 10230, Washington,
D.C. 20503.
Dated: September 30, 1994.
Charlotte Whitenight,
Reports Clearance Officer, Social Security Administration.
[FR Doc. 94-24767 Filed 10-6-94; 8:45 am]
BILLING CODE 4190-29-P
