00-30403. Agency Information Collection Activities: Proposed Request and Comment Request

In compliance with Public Law 104-13, the Paperwork Reduction Act of 1995, SSA is providing notice of its information collections that require submission to the Office of Management and Budget (OMB). The Social Security Administration (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.

I. The information collections listed below will be submitted to OMB within 60 days from the date of this notice. Therefore, comments and recommendations regarding the information collections would be most useful if received by the Agency within 60 days from the date of this publication. Comments should be directed to the SSA Reports Clearance Officer at the address listed at the end of this publication. You can obtain a copy of the collection instruments by calling the SSA Reports Clearance Officer on [phone], or by writing to him at the address listed at the end of this publication.

1. Application for Benefits Under The Federal Mine And Safety And Health Act Of 1977, as Amended (Widow's Claim, Child's Claim And Dependent's Claim)—0960-0118. Section 402(g) and Section 412(a) of the Federal Mine Safety and Health Act provide that those widows, surviving children and dependent parents, brothers and sisters who are not currently receiving benefits on the deceased miner's account must file the appropriate application for Black Lung benefits within 6 months of the deceased miner's death. Forms SSA-47-F4, SSA-48-F4, and SSA-49-F3 are used to collect the information needed by the SSA to determine eligibility for benefits. The respondents are widows, surviving children and dependents (parents, brothers or sisters) who are not currently receiving Black Lung benefits on the deceased miner's account.

	SSA-47-F4	SSA-48-F4	SSA-49-F3
Number of Respondents	600	600	600
Frequency of Response	1	1	1
Average Burden Per Response (minutes)	11	11	11
Estimated Annual Burden (hours)	110	110	110

2. Representative Payee Report of Benefits and Dedicated Account—0960-0576. Form SSA-6233 is used to ensure that the representative payee is using the benefits received for the beneficiary's current maintenance and personal needs and that expenditures of funds from the dedicated account are in compliance with the law. The respondents are individuals and organizational representative payees who are required by law to establish a separate (“dedicated”) account in a financial institution for certain past-due SSI benefits.

Number of Respondents: 30,000.

Frequency of Response: 1.

Average Burden Per Response: 20 minutes.

Estimated Annual Burden: 10,000 hours.

3. Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits—0960-0024. SSA uses the information collected on Form SSA-787 to determine an individual's capability, or lack thereof, to handle his or her own benefits. The information also provides SSA with leads to follow in selecting a representative payee, if needed. The respondents are physicians of these beneficiaries.

Number of Respondents: 120,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 20,000 hours.

4. Request for Internet Service—Password—0960-NEW. SSA will collect and use information to establish a PIN/Password Data File. The file will be used to allow customers to conduct electronic business with the Agency. SSA will request the following information: Name, Social Security Number, Password Request Code, Last Month Payment Amount and Director Deposit Account Number (if applicable). The respondents are individuals electing to conduct business with SSA in the electronic medium.

Number of Respondents: 250,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 41,667 hours.

5. Internet Social Security Benefits Applications (also known as ISBA)—0960-0618. The ISBA (formerly the Internet Retirement Insurance Benefit or IRIB application) is one application that the Commissioner of Social Security will prescribe to meet the requirement to file an application for title II retirement and/or spouse's benefits. The ISBA will be available on the Social Security Administration Internet site and will enable individuals to complete the application electronically on their own and submit the application over the Internet. Until SSA develops an acceptable electronic signature process, applicants will also print, sign and mail the IBSA statement with the required evidence that supports their application. The information that SSA collects will be used to determine entitlement to retirement insurance benefits. The respondents are individuals and their spouses, if applicable, who choose to apply for title II benefits over the Internet.

Number of Respondents: 189,764.

Frequency of Response: 1.

Average Burden Per Response: 20 minutes.

Estimated Annual Burden: 63,255 hours.

6. Discrimination Complaint Form—0960-0585. The information collected on form SSA-437 will be used by SSA to investigate and informally resolve complaints of discrimination based on race, color, national, origin, sex, age religion and retaliation in any program or activity conducted by SSA. A person who believes that he or she has been discriminated against on any of the above bases may file a written complaint of discrimination. The information will be used to identify the complainant; identify the alleged discriminatory act; ascertain the date of such alleged act; obtain the identity of the individual(s)/facility/component that allegedly discriminated; and ascertain other relevant information that would assist in the investigation and resolution of the complaints. The respondents are individuals who allege discrimination on the grounds described above.

Number of Respondents: 300.

Frequency of Response: 1.

Average Burden Per Response: 1 hour.

Estimated Annual Burden: 300 hours.

7. Claimant's Statement When Request for Hearing is Filed and the Issue is Disability—0960-0316. SSA requests that a claimant complete an HA-4486 when a claim for title II disability benefits or title XVI Supplemental Security Income benefits is denied and the claimant wishes a hearing before an Administrative Law Judge (ALJ). SSA uses this form to obtain updated information on the claimant's medical treatment to assist the ALJ in preparing for the hearing and in issuing a decision on entitlement to benefits. The respondents are individuals whose claims have been denied and who want a hearing before an ALJ.

Number of Respondents: 442,720.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 110,680.

II. The information collections listed below have been submitted to OMB for clearance. Written comments and recommendations on the information collections would be most useful if received within 30 days from the date of this publication. Comments should be directed to the SSA Reports Clearance Officer and the OMB Desk Officer at the addresses listed at the end 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.

1. National Teacher Questionnaire (SSA-5665-BK), and Information About the Working Age Child (SSA-5665-SUPP)—0960-New. The information collected on forms SSA-5665-BK and SSA-5665-Sup is used by the Social Security Administration (SSA) and the State Disability Determination Services (DDS) to obtain descriptions of children claiming SSI benefits based on disability and their ability to function on a daily basis. The forms will be used for initial determinations of eligibility, in appeals and in initial continuing disability reviews.

These forms are being developed because the forms currently used by the DDSs vary in format and content. It was decided that for the sake of a uniform national childhood program (and with this information in hand and the sensitivity of this population), the time has come for a National Teacher Questionnaire and Information About the Working Age Child. The respondents are the educational community and small businesses that educate and/or employ applicants for Supplemental Security Income for the aged, blind, and Disabled.

	SSA-5665-BK	SSA-5665-Sup
Number of Respondents	475,000	125,000
Frequency of Response	1	1
Average Burden Per Response (minutes)	15-20	5-10
Estimated Annual Burden (hours)	158,333	20,833

2. Beneficiary Recontact Report—0960-0536. SSA collects the information on Form SSA-1587 to ensure that eligibility for benefits continues after entitlement is established. SSA asks children ages 15, 16, and 17 information about marital status to detect overpayments and avoid continuing payment to those no longer entitled. Studies show that children who marry fail to report the marriage, which is a terminating event. The respondents are applicants for Title II (Old-Age, Survivors and Disability Insurance) Children/Beneficiaries who are ages 15, 16, and 17.

Number of Respondents: 982,357.

Frequency of Response: 1.

Average Burden Per Response: 3 minutes.

Estimated Annual Burden: 49,118 hours.

3. Questionnaire About Employment or Self-Employment Outside the United States, 0960-0050. This information is used by SSA to determine whether work performed by beneficiaries outside the United States (U.S.) is cause for deductions from their monthly benefits; to determine which of two work tests (foreign or regular) is applicable; and to determine the months, if any, for which deductions should be imposed. The respondents are beneficiaries living and working outside the U.S.

Number of Respondents: 20,000.

Frequency of Response: 1.

Average Burden Per Response: 12 minutes.

Estimated Annual Burden: 4,000 hours.

(SSA Address)

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

(OMB Address)

Office of Management and Budget, OIRA, Attn: Desk Officer for SSA, New Executive Office Building, Room 10230, 725 17th St., NW., Washington, DC 20503.

Date: November 22, 2000.

Elizabeth A. Davidson,

Acting Reports Clearance Officer, Social Security Administration.