01-25303. Agency Information Collection Activities: Comment Request and Emergency 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 Pub. L. 104-13 effective October 1, 1995, The Paperwork Reduction Act of 1995. 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 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 and at the following addresses:

(OMB) Office of Management and Budget, Attn: Desk Officer for SSA, New Executive Office Building, Room 10230, 725 17th St., NW, Washington, D.C. 20503

(SSA) Social Security Administration, DCFAM, Attn: Frederick W. Brickenkamp, 1-A-21 Operations Bldg., 6401 Security Blvd., Baltimore, MD 21235

I. 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 on [phone], or by writing to him at the address listed above.

1. National Study of Health and Activity (NSHA)—0960-0609. The Social Security Administration is sponsoring the NSHA to serve as the cornerstone of SSA's future disability policy development and research agenda. NSHA is a national disability study that consists of gathering information from interviews, medical examinations and medical records to be used to make simulated Disability Determination Service disability decisions. A pilot study was conducted in 2000 and revisions were made to the study instruments and procedures based on the analysis of the pilot data. To test the usability of the revisions, a pretest of the survey instruments and procedures is necessary prior to beginning the main study.

This pretest will be conducted on volunteers obtained from SSA disability rolls and nondisabled individuals recruited from the community. Pretesting activities will encompass all components of the study including screening, interviewing, medical examinations, collection of medical records, and assembling a folder of all data for the study's simulated disability decision process. A major goal of the proposed pretest is to improve the content of the disability determination folder. Once the results from this pretest are available, the NSHA instruments and procedures will be further refined for the dress rehearsal and main study.

SSA will screen up to 400 individuals to obtain 140 volunteers to participate in activities (2) through (5) below. SSA will contact approximately 420 health care providers to obtain the medical records of the volunteers (item (6) below). The public reporting burden is as follows:

Information Collection Activity	Number of respondents	Frequency of response	Average hours per response	Estimated annual burden
(1) Recruitment screening	400	1	.17	68
(2) Household screener	140	1	.33	46
(3) Sample person interview	140	1	1.5	210
(4) Respondent medical exam information	140	1	2	280
(5) Comments on pretest materials	140	1	.25	35
(6) Collecting medical evidence of record from healthcare provider	420	1	.5	210
Total				849

2. Request for Hearing—0960-0269. The information collected on Form HA-501 is used by the Social Security Administration (SSA) to process a request for hearing on an unfavorable determination of entitlement or eligibility for benefits administered by SSA. The respondents are individuals whose claims for benefits are denied and who request a hearing on the denial.

Number of Respondents: 556,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 92,667 hours.

3. Request for Review of Hearing Decision/Order—0960-0277. The information collected on form HA-520 is needed to afford claimants their statutory right under the Social Security Act to request review of a hearing decision. The data will be used to determine the course of action appropriate to resolve each issue. The respondents are claimants denied or dissatisfied with a decision made regarding their claim.

Number of Respondents: 80,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Average Burden: 13,333 hours.

4. Disability Determination And Transmittal—0960-0437. The information collected on Form SSA-831-U3/C3 is used by SSA to document the State agency determination as to whether an individual who applies for disability benefits is eligible for those benefits based on his/her alleged disability. SSA also uses the form for program management and evaluation. The respondents are State Disability Determination Services (DDS) adjudicating Title II and Title XVI Disability claims.

Number of Respondents: 2,860,859.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 715,215 hours.

Cessation or Continuance of Disability or Blindness Determination—0960-0443. The information on Form SSA-832-U3/C3 is used by SSA to document determinations as to whether an individual's disability benefits should be terminated or continued on the basis of his/her impairment. The respondents are State DDS employees adjudicating Title XVI Disability claims.

Number of Respondents: 600,758.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 300,379 hours.

5. Cessation Or Continuance Of Disability Or Blindness Determination And Transmittal—0960-0442. The information on Form SSA-833-U3/C3 is used by SSA to make determinations of whether individuals receiving title II disability benefits should continue to be unable to engage in substantial gainful activity and are still eligible to receive benefits. The respondents are State DDS employees.

Number of Respondents: 466,124.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 233,062 hours.

6. Modified Benefit Formula Questionnaire—0960-0395. The information collected on Form SSA-150 is needed by SSA to determine the correct formula to use in computing Social Security benefits for someone who also receives benefits from employment not covered by Social Security. The respondents consist of claimants for Social Security benefits who are also entitled to benefits not covered by Social Security.

Number of Respondents: 90,000.

Frequency of Response: 1.

Average Burden Per Response: 8 minutes.

Estimated Average Burden: 12,000 hours.

II. Agency Information Collection Activities: Emergency Consideration Request SSA is requesting emergency consideration under 20 CFR 1320.13 (a) (2) (iii) from OMB by October 25, 2001, of the information collections listed below.

1. State Agency Ticket Assignment Form, SSA-1365, State Vocational Rehabilitation Ticket to Work Information Sheet, SSA-1366 and Individual Work Plans (IWP) Information Sheet, SSA-1367-0960-NEW.

Background

Public Law (Pub. L.) 106-170, the Ticket to Work and Work Incentives Improvement Act of 1999, creates a new Ticket to Work (TTW) program for providing work access services to SSA beneficiaries. The new program requires SSA to monitor the services provided under the Law. SSA has developed three data collection forms that request service provider and beneficiary information that is essential to SSA's administration of this new program. Employment networks (ENs) providing TTW services under contracts with SSA are required to submit to SSA the information listed in form SSA-1367. State vocational rehabilitation agencies (VRAs) that provide services to SSA beneficiaries under either the traditional VR reimbursement mechanism or the new Ticket to Work program are required to submit to SSA the information listed in forms SSA-1365 and SSA-1366. SSA does not require that ENs or VRAs use forms SSA-1366 and SSA-1367 per se, but does require that any alternative forms submitted in place of these SSA forms include the SSA listed information at a minimum. VRAs are required to submit from SSA-1365 in all cases as a means of assigning Tickets to VRAs.

a. State Agency Ticket Assignment Form-SSA-1365. The information collected on this form will be used by SSA's contracted Program Manager (PM) to perform the task of assigning beneficiaries' tickets and monitoring the use of tickets under the Ticket to Work and Self-Sufficiency Program. The State VRA answers the questions and the beneficiary reviews the data and if in agreement will sign the form acknowledging their Ticket assignment.

The respondents are State VR agencies.

Number of Respondents: 21.

Frequency of Response: 4,048 annually per respondent.

Average Burden Per Response: 3 minutes.

Estimated Annual Burden: 4,250 hours.

b. State Vocational Rehabilitation Ticket to Work Information Sheet-SSA-1366. The information collected on Form SSA-1366 will be used by SSA's contracted PM when a State VRA elects to participate in the Program as an EN. In this case, form SSA-1366, when combined with the SSA-1365, is intended to meet the minimum information requirements for IWPs and to monitor the appropriateness of the IWPs as required under the Pub. L. 106-107. The respondents are VRAs acting as ENs under the Ticket to Work Program.

Number of Respondents: 21.

Frequency of Response: 132 annually per respondent.

Average Burden Per Response: 2 minutes.

Estimated Annual Burden: 92 hours.

Please Note:

The Ticket to Work Program is being implemented in stages. The above represents the initial phase of the program with 13 participating states that include 21 State VR agencies. As the program continues to be phased in, each initial program year will result in a larger number of new tickets for the participating State VRs because existing clients will also be brought into the program.

c. Individual Work Plans (IWP) Information Sheet-SSA-1367. The information collected on Form SSA-1367 will be used to monitor the appropriateness of IWPs that have been assigned to ENs under the Ticket To Work Act. The respondents are ENs under the ticket to work program.

Number of Respondents: 31,450.

Frequency of Response: 1 annually per respondent.

Average Burden Per Response: 3 minutes.

Estimated Annual Burden: 1,573 hours.

Dated: Octobert 2, 2001.

Frederick W. Brickenkamp,

Reports Clearance Officer.