2011-28729. 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 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. This notice includes revisions to OMB-approved information collections and one new information collection request.

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, email, 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], Email address: [e-mail];

(SSA), Social Security Administration, DCRDP, Attn: Reports Clearance Officer, 107 Altmeyer Building, 6401 Security Blvd., Baltimore, MD 21235, Fax No.: [phone], Email 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 January 6, 2012. Individuals can obtain copies of the collection instruments by calling the SSA Reports Clearance Officer at [phone] or by writing to the above email address.

1. Homeless with Schizophrenia Presumptive Disability Pilot Demonstration—45 CFR 46.101(b)(5)—0960-NEW. The Federal Strategic Plan to Prevent and End Homelessness 2010 calls on Federal agencies to work in partnership with State and local governments and with the private sector to end homelessness. A specific objective of the Strategic Plan is to increase economic security by improving access to mainstream programs and services.

In response to and in support of the President's efforts to end homelessness, SSA has developed the Homeless with Schizophrenia Presumptive Disability Pilot Demonstration, which tests both administrative improvements to the Supplemental Security Income (SSI) application process and interventions that provide financial stability to individuals who are homeless. The pilot will test strategies that would remove the barriers homeless adult applicants with schizophrenia or schizoaffective disorder experience when completing the SSI application process.

SSA uses two key forms to conduct the demonstration: The Research Subject Information and Consent Form and the Schizophrenia Presumptive Disability Recommendation Form. The consent form provides assurances from the participants that they understand the demonstration project and voluntarily are consenting to participate in it. The Presumptive Disability Recommendation form, filled out by a medical authority, provides information on how the applicant meets the disability criteria necessary to qualify for SSI benefits. SSA uses the information in making a presumptive disability determination. Respondents are homeless, adult SSI applicants with schizophrenia or schizoaffective disorder.

Type of Request: Request for a new information collection.

Form	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
Consent Form	200	1	120	400
Presumptive Disability Recommendation Form	16	13	10	35
Totals	216			435

2. Partnership Questionnaire—20 CFR 404.1080-1082—0960-0025. SSA considers partnership income in determining entitlement to Social Security benefits. SSA uses information from Form SSA-7104 to determine several aspects of eligibility for benefits, including the accuracy of reported partnership earnings, the veracity of a retirement, and lag earnings. The respondents are applicants for, and recipients of, Title II Social Security Old Age, Survivors, and Disability Insurance benefits.

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-7104	12,350	1	30	6,175

3. Statement of Funds You Provided to Another and Statement of Funds You Received—20 CFR 404.1520(b), 404.1571-.1576, 404.1584-.1593 and 416.971-.976—0960-0059. SSA uses Form SSA-821-BK to collect employment information to determine whether recipients have worked after becoming disabled and, if so, whether the work is substantial gainful activity. SSA field offices use form SSA-821-BK to obtain work information during the initial claims process, the continuing disability review process, and for SSI claims involving work issues. SSA's processing centers and the Office of Disability and International Operations use the form to obtain post-adjudicative work issues from recipients. SSA reviews and evaluates the data to determine if the applicant or recipient meets the disability requirements of the law. The respondents are applicants and recipients of Title II Social Security and SSI disability payments.

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

Collection instrument	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-821-BK	300,000	1	40	200,000

4. Application for Search of Census Records for Proof of Age—20 CFR 404.716—0960-0097. When preferred evidence of age is not available or the available evidence is not convincing, SSA may request the U.S. Department of Commerce, Bureau of the Census, to search its records to establish a claimant's date of birth. SSA collects information from claimants using the SSA-1535-U3 to provide the Census Bureau with sufficient identification information to allow an accurate search of census records. Additionally, the Census Bureau uses a completed, signed SSA-1535-U3 to bill SSA for the search. The respondents are applicants for Social Security benefits who need to establish their date of birth as a factor of entitlement.

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

Collection instrument	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-1535-U3	18,030	1	12	3,606

5. Modified Benefit Formula Questionnaire—Foreign Pension—0960-0561. SSA uses Form SSA-308 to determine exactly how much (if any) of a foreign pension may be used to reduce the amount of Title II Social Security retirement or disability benefits under the modified benefit formula. The respondents are applicants for Title II Social Security retirement or disability benefits who receive foreign pensions.

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-308	13,452	1	10	2,242

6. Medical Source Statement of Ability To Do Work-Related Activities (Physical and Mental)—20 CFR 404.1512-404.1514, 404.912-404.914, 404.1517, 416.917, 404.1519-404.1520, 416.919-416.920, 404.946, 416.946, 404-1546—0960-0662. In some instances, when a claimant appeals a denied disability claim and the claimant's medical sources cannot or will not give the agency sufficient evidence to determine whether the claimant is disabled, SSA may ask the claimant to have a consultative examination at the agency's expense. The medical providers who perform these consultative examinations provide a statement on Forms HA-1151 and HA-1152 about the claimant's disability and ability to perform work-related activities. SSA uses the information to assess the work-related physical and mental capabilities of claimants who appeal SSA's previous determination on their issue of disability. The respondents are medical sources who provide reports based either on existing medical evidence or on consultative examinations.

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

Collection instrument	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
HA-1151	5,000	24	15	30,000
HA-1152	5,000	24	15	30,000
Totals	10,000			60,000

7. Medicare Subsidy Quality Review Forms—20 CFR 418(b)(5)—0960-0707. The Medicare Modernization Act of 2003 mandated the creation of the Medicare Part D prescription drug coverage program and provides certain subsidies for eligible Medicare beneficiaries to help pay for the cost of prescription drugs. As part of its stewardship duties of the Medicare Part D subsidy program, SSA must conduct periodic quality review checks of the information Medicare beneficiaries report on their subsidy applications (Form SSA-1020). SSA uses the Medicare Quality Review program to conduct these checks. The respondents are applicants for the Medicare Part D subsidy whom SSA chose to undergo a quality review.

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

Form number and name	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-9301 (Medicare Subsidy Quality Review Case Analysis Questionnaire)	3,500	1	30	1,750
SSA-9302 (Notice of Quality Review Acknowledgement Form for those with Phones)	3,500	1	15	875
SSA-9303 (Notice of Quality Review Acknowledgement Form for those without Phones)	350	1	15	88
SSA-9304 (Checklist of Required Information; burden accounted for with forms SSA-9302, SSA-9303, SSA-9311, SSA-9314)
SSA-9308 (Request for Information)	7,000	1	15	1,750
SSA-9310 (Request for Documents)	3,500	1	5	292
SSA-9311 (Notice of Appointment—Denial— Reviewer Will Call)	450	1	15	113
SSA-9312 (Notice of Appointment—Denial—Please Call Reviewer)	50	1	15	13
SSA-9313 (Notice of Quality Review Acknowledgement Form for those with Phones)	2,500	1	15	625
SSA-9314 (Notice of Quality Review Acknowledgement Form for those without Phones)	500	1	15	125
SSA-8510 (Authorization to the Social Security Administration to Obtain Personal Information)	3,500	1	5	292
Totals	24,850			5,923

8. Application to Collect a Fee for Payee Services—20 CFR 416.640(a) and 20 CFR 416.1103(f)—0960-0719. Sections 205(j)(4)(A) and (B) and 1631(a)(2) of the Social Security Act (Act) allow SSA to authorize certain organizational representative payees to collect a fee for providing payee services. Before an organization may collect this fee, they complete and submit Form SSA-445. SSA uses the information to determine whether to authorize or deny permission to collect fees for payee services. The respondents are private sector businesses or State and local government offices applying to become fee-for-service organizational representative payees.

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

Collection instrument	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
Private sector business	90	1	10	15
State/local government offices	10	1	10	2
Totals	100			17

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 December 7, 2011. Individuals can obtain copies of the OMB clearance package by calling the SSA Reports Clearance Officer at [phone] or by writing to the above email address.

Report on Individual with Mental Impairment—20 CFR 404.1513 & 416.913—0960-0058. SSA uses Form SSA-824 to obtain medical evidence from medical sources who have treated a Social Security disability claimant for a mental impairment. SSA uses the information to establish whether a claimant filing for disability benefits has a mental impairment that meets the statutory definition of disability in accordance with the Social Security Act. The respondents are mental impairment treatment providers.

Note:

This is a correction notice. SSA published this information collection as an extension on August 1, 2011 at 76 FR 45902. Since we are revising the Privacy Act Statement, this is now a revision of an OMB-approved information collection. We are also updating the burden data.

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

Collection instrument	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-824	500	1	36	300

Dated: November 2, 2011.

Faye Lipsky,

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