E8-29332. 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 a revision to an OMB-approved information collection.

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 the 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 the SSA Reports Clearance Officer to the addresses or fax numbers listed below.

(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,

1332 Annex Building,

6401 Security Blvd.,

Baltimore, MD 21235,

Fax: [phone],

E-mail address: [e-mail],

I. The information collection below is pending at SSA. SSA will submit it to OMB within 60 days from the date of this notice. Therefore, your comments would be most helpful if you submit them to SSA within 60 days from the date of this publication. Individuals can obtain copies of the collection instrument by calling the SSA Reports Clearance Officer at 410-965-3758 or by writing to the email address listed above.

1. Claimant's Recent Medical Treatment—20 CFR 404.1512 and 416.912—0960-0292 Form HA-4631 is a questionnaire used by SSA to obtain updated medical evidence. Each claimant who requests a hearing before an Administrative Law Judge (ALJ) has a right to such a hearing once the Disability Determination Service (DDS), at the Reconsideration level, has denied the claim. SSA requests the claimant complete and return the HA-4631 if the claimant's file does not reflect a complete medical history. Because the claimant's situation may change over time, as the claimant proceeds through the appeals process, ALJs must obtain the information on Form HA-4631 to update and complete the record and to verify the accuracy of information previously provided. It is by this process, ALJs can ascertain whether the claimant's situation has changed. The ALJ and Hearing Office (HO) staff use the response to make hearing arrangements for consultative examination(s) and the attendance of an expert witness(es), if appropriate. At the hearing, the ALJ offers any completed questionnaires as exhibits and may use them to refresh the claimant's memory, and to inquire into the matters at issue. The respondents are claimant's requesting hearings on entitlement to benefits based on disability under Titles II and/or XVI of the Social Security Act.

Type of Request: Extension of an OMB-Approved Information Collection.

Number of Respondents: 350,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 58,333 hours.

2. Medicaid Use Report—20 CFR 416.268—0960-0267. SSA uses the information required by this regulation to determine if an individual is entitled to special Title XVI Supplemental Security Income (SSI) payments and, consequently, to Medicaid benefits. The Respondents are SSI recipients for whom SSA has stopped payments based on earnings.

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

Number of Respondents: 60,000.

Frequency of Response: 1.

Average Burden Per Response: 3 minutes.

Estimated Annual Burden: 3,000 hours.

3. Application for Parent's Insurance Benefits—20 CFR 404.370-404.374, 20 CFR 404.601-404.603—0960-0012. The Social Security Administration uses Form SSA-7 to collect information used to entitle an individual to his or her parent's insurance benefits. The respondents are claimants who wish to apply to receive their parent's insurance benefits.

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

Number of Respondents: 315.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 79 hours.

4. Partnership Questionnaire—20 CFR 404.1080-1082—0960-0025. The Social Security Administration uses the information reported on Form SSA-7104 to establish several aspects of eligibility for Social Security benefits, including the accuracy of reported partnership earnings, the veracity of a retirement, and lag earnings. The respondents are applicants for, and recipients of, Social Security Old Age, Survivors, and Disability Insurance Benefits.

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

Number of Respondents: 12,350.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 6,175 hours.

5. Request for Waiver of Overpayment Recovery or Change in Repayment Notice—20 CFR 404.502—404.513, 404.515 and 20 CFR 416.550—416.570, 416.572-0960-0037. The overpaid individual uses the SSA-632-BK to request a waiver of recovery of an overpayment. The individual explains why they feel they are without fault in causing the overpayment and provides financial information, so SSA can determine whether recovery would cause financial hardship. If the individual agrees to repay the overpayment, they can use the SSA-632-BK to inform SSA they want to repay at a monthly rate that would take more than thirty-six months to recover the overpayment. The individual can also use the SSA-632-BK to request a different rate of recovery. In those cases, they must provide financial information to SSA for a determination of how much the overpaid person can afford to repay each month. Respondents are overpaid beneficiaries or claimants who are requesting a waiver of recovery of the overpayment, or a lesser rate of withholding.

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

Reason for completing form	Number of respondents	Frequency of response	Average burden per response	Total annual burden
Request Waiver	400,000	1	2 hours	800,000
Request Change	100,000	1	45 minutes	75,000
Totals	500,000			875,000

6. 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. Form SSA-821-BK is used by SSA field offices to obtain work information from recipients while conducting face-to-face interviews, telephone interviews and by mail, during the initial claims process, during the continuing disability review process and whenever work issues arise in SSI claims. SSA's Processing Centers and the Office of Disability and International Operations use the form to obtain post-adjudicative work issues from recipients by mail. The primary purpose of this form is to collect recipient employment information in order to determine whether or not recipients have worked in employment after becoming disabled and, if so, whether the work is SGA. SSA will review and evaluate the data to determine if the recipient continues to meet the disability requirement of the law. The respondents are Social Security Disability Applicants, Beneficiaries, and Supplemental Security Income Applicants.

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

Number of Respondents: 300,000.

Frequency of Response: 1.

Average Burden Per Response: 45 minutes.

Estimated Annual Burden: 225,000 hours.

7. Application for Supplemental Security Income —20 CFR 416.305-416.335, Subpart C—0960-0444. Form SSA-8001-BK collects information SSA uses to determine an applicant's eligibility for SSI, and the amount of SSI benefits. SSA employees secure this information during interviews conducted with members of the public who wish to file for SSI benefits. This form is used for two purposes: (1) To formally deny Supplemental Security Income benefits for non-medical reasons when information provided by the applicant results in ineligibility; OR (2) to establish a disability claim, but defer the complete development of non-medical issues until the disability is approved. The respondents are recipients for Supplemental Security Income benefits.

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

Form type	Number of respondents	No. of minutes to complete form	Burden hours
MSSIC	711,135	15	177,784
MSSIC/Signature Proxy	237,045	14	55,311
Paper	19,351	18	5,805
Totals:	967,531		238,900

II. SSA has submitted the information collections listed below 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 at 410-965-3758, or by writing to the above listed address.

1. Accelerated Benefits Demonstration Project—0960-0747

Background

In early 2007, SSA obtained OMB approval for the Accelerated Benefits Demonstration Project, a multi-phase study designed to assess whether providing new SSDI recipients with certain benefits would stabilize or improve their health and help them return to work early. In this long-term study, we assigned new SSDI recipients (i.e., those who had just begun receiving disability benefits and who had at least 18 months remaining before they qualified for Medicare) to three groups. The three groups consisted of: (1) A control group who would just receive regular SSDI benefits; (2) a treatment group who would receive immediate access to health care benefits; and (3) a treatment group who would receive health care benefits and additional care management, employment, and benefits services and support. The study, which research contractors and health care experts are conducting for SSA, assess if the health care and other benefits help beneficiaries improve and return to work earlier, and asses if there is a difference between the treatment groups.

Update/Current ICR

Having (1) Assigned eligible beneficiaries into one of the three participant groups described above and (2) conducted a baseline and six-month follow-up surveys with these beneficiaries, SSA is now ready to move on to the next phase of the study: A 12-month follow-up survey. This ICR is for the 12-month follow-up survey, which we plan to conduct beginning in March 2009. We will use telephone interviews for the survey, with in-person follow-up for non-responders as necessary. We will attempt to contact all 2,000 participants and expect to complete follow-up interviews with 1,600 of them (80 percent). The purpose of the survey is to explore participants' experiences after one year in the program, which will provide initial data on the effects of the health care and “heath care plus” treatments. The respondents are SSDI beneficiaries participating in this study.

Burden Data for 12-Month Follow-Up Survey

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

Number of Respondents: 1,600.

Frequency of Response: 1.

Average Burden per Response: 45 minutes.

Estimated Annual Burden: 1,200 hours.

2. Request To Be Selected as a Payee—20 CFR 404.2010-404.2055, 416.601-416.665—0960-0014

An individual applying to be a representative payee for a Social Security or SSI recipient completes Form SSA-11-BK. SSA designed the form to aid the investigation of a payee applicant. SSA uses the information to establish the applicant's relationship to the beneficiary, his/her justification and his/her concern for the beneficiary, as well as the manner in which the applicant will use the benefits. The respondents are representative payee applicants for Titles II, VIII, and XVI.

Type of Request: Revision of an OMB-approved information collection.*11/60.

Number of Respondents: 1,500,000.

Estimated Annual Burden: 248,335 hours.

Individuals/Households (90%):

Collection method	Number of respondents	Frequency of response	Average burden per response	Total annual burden
Representative Payee System (RPS)	135,000	1	10.5	23,625
RPS/Signature Proxy	765,000	1	9.5	121,125
Paper Version	450,000	1	10.5	78,750
Totals	1,350,000			223,500

Private Sector (9%):

Collection method	Number of respondents	Frequency of response	Average burden per response	Total annual burden
RPS	13,500	1	10.5	2,363
RPS/Signature Proxy	76.500	1	9.5	12,113
Paper Version	45,000	1	10.5	7,875
Totals	135,000			22,351

State/Local/Tribal Government (1%):

Collection method	Number of respondents	Frequency of response	Average burden per response	Total annual burden
RPS	1,500	1	10.5	263
RPS/Signature Proxy	8,500	1	9.5	1,346
Paper Version	5,000	1	10.5	875
Totals	15,000			2,484
Grand Total:	1,500,000			248,335

3. 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 the claimant for a mental impairment. SSA uses the information collected on this form to establish whether a claimant filing for disability benefits has a mental impairment that meets the statutory definition of disability in the Social Security Act. The respondents are mental impairment treatment facilities.

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

Type of respondents	Number of respondents	Frequency of response	Average burden per response	Total annual burden
Private Sector	25,000	1	36	15,000
State DDSs (State/Local Government)	25,000	1	36	15,000
Totals	50,000			30,000

4. SSI Notice of Interim Assistance Reimbursement (IAR)—0960-0546

Within this Notice, the phrase “IAR agency” refers to either a state or a local agency that receives Interim Assistance Reimbursement (IAR).

Section 1631(g) of the Social Security Act authorizes SSA to reimburse an IAR agency from an individual's retroactive Supplemental Security Income (SSI) payment for assistance the IAR agency gave the individual for meeting basic needs while an SSI claim was pending or SSI payments were suspended or terminated. The state or local agency must have an IAR agreement with SSA to participate in the IAR program.

The individual receiving the IAR payment must sign an authorization form with an IAR agency to allow SSA to repay the IAR agency for funds paid in advance prior to SSA's determination on the individual's claim. The authorization represents the individual's intent to file for SSI if he/she has not filed an application prior to SSA receiving the authorization.

Agencies who wish to enter into an IAR agreement with SSA must meet the following requirements:

(a) Reporting Requirements: Each IAR agency agrees to: (1) Notify SSA of receipt of an authorization for initial claims or cases being appealed, and submit a copy of that authorization either through a manual or electronic process; (2) inform SSA of the amount of reimbursement; (3) submit a written request for dispute resolution on a determination; (4) notify SSA of interim assistance paid (using the SSA-8125 or the SSA-L8125-F6); (5) inform SSA of any deceased claimants who participate in the IAR program; and (6) review and sign an agreement with SSA.

(b) Recordkeeping Requirements: The IAR agencies agree to retain all notices, agreement, authorizations, and accounting forms for the period defined in the IAR agreement for the purposes of SSA verifying transactions covered under the agreement.

(c) Third Party Disclosure Requirements: Each participating IAR agency must agree to send written notices from the IAR agency to the recipient regarding payment amounts and appeal rights.

(d) Periodic Review of Agency Accounting Process: The IAR agency must make available for SSA review and verification the IAR accounting records of paid cases. SSA conducts reviews either onsite or through the mail of the authorization forms, notices to the claimant and accounting forms. Upon completion of the review, SSA provides a written report of findings to the IAR agency director.

SSA is currently in the process of automating the IAR process. SSA completed Phase 1 of the automated process, called eIAR, in June 2008 by creating a database that will allow real-time updates for IAR cases. Phase 2 (targeted for 2009) will eliminate the paper Forms SSA-8125 and SSA-L8125-F6. SSA will receive and send all exchanges of information through electronic mail (e-mail) and a secure Internet site. The eIAR process will store IAR agency accounting and SSA payment data for use by SSA regional office staff for auditing the IAR agency records. The IAR agency will have access to IAR information (past and present) for their purposes. Respondents are IAR agencies.

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

Reporting Requirements

Type of request	Number of respondents	Frequency of response	Number of responses	Average burden per response (minutes)	Estimated annual burden hours (hours)
Notification of Receipt of Authorization (Electronic Process)	11	8,856	97,416	1	1624
Submission of copy of Authorization (Manual Process)	26	792	20,592	3	1030
Notification to SSA of Amount of Reimbursement	39	577	22,503	30	11,252
Request for Determination—Dispute Resolution	2	1	2	15	1
Form SSA-8125	39	1282	49,998	10	8,333
Form SSA-L8125-F6	39	1282	49,998	10	8,333
eIAR Process	39	2564	99,996	8	13,333
Notification to SSA of Deceased Claimant	20	2	40	15	10
Review/Signing Agreements	39	1	39	1 12	468
1 Hours.

Recordkeeping Requirements

	Number of respondents	Frequency of response	Number of responses	Average burden per response (minutes)	Estimated annual burden hours
Maintenance of Authorization Forms	39	3,189	124,371	3	6219
Maintenance of Accounting Forms and Notices	39	3,189	124,371	3	6219

Third Party Disclosure Requirements

	Number of respondents	Frequency of response	Number of responses	Average burden per response (minutes)	Estimated annual burden hours
Written Notice from IAR agency to Recipient Regarding Amount of Payment	39	576	22,464	7	2621

Periodic Review of Agency Accounting Process

	Number of respondents	Frequency of response	Number of responses	Average burden per response (hours)	Estimated annual burden hours
Retrieve and Consolidate Authorization and Accounting Forms	12	1	12	3	36
Participate in Periodic Review	12	1	12	16	192
Correct Administrative and Accounting Discrepancies	6	1	6	4	24

Total Administrative Burden

	Number of respondents	Frequency of response	Number of responses	Average burden per response	Estimated annual burden hours
Totals	39		611,820		59,695

5. General Request for Social Security Records—eFOIA—20 CFR 402.130—0960-0716

SSA uses the information collected on this electronic request for Social Security records to respond to the public's request for information under the Freedom of Information Act (FOIA). SSA also tracks the number and type of requests, fees charged and payment amounts, and whether SSA responds within the required 20 days. Respondents are members of the public including individuals, institutions, or agencies requesting information/documents under FOIA.

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

Number of Respondents: 5,000.

Frequency of Response: 1.

Average Burden Per Response: 3 minutes.

Estimated Annual Burden: 250 hours.

Dated: December 5, 2008.

John Biles,

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