02-2429. Agency Information Collection Activities: Notice of Office of Management and Budget (OMB) Approval, Proposed Request and Comment Request

ACTION: Notice of OMB Approval

As required by the Paperwork Reduction Act of 1995 (44 U.S.C. 3507), the Social Security Administration (SSA) is providing notice of OMB's approval of the information collections in the final rule, Revised Medical Criteria for Determination of Disability, Musculoskeletal System and Related Criteria, part 404, subpart, appendix 1. In accordance with the Paperwork Reduction Act, persons are not required to respond to an information collection unless it displays a valid Office of Management and Budget control number. The OMB Number is 0960-0642, which expires December 31, 2004.

ACTION: Proposed Request and Comment 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, DC 20503.

(SSA), Social Security Administration, DCFAM, Attn: Reports Clearance Officer, 1-A-21 Operations Bldg., 6401 Security Blvd., Baltimore, MD 21235.

I. The information collections listed below will be submitted to OMB within 60 days from the date of this notice. Therefore, your comments should be submitted to SSA within 60 days from the date of this publication. You can obtain copies of the collection instruments by calling the SSA Reports Clearance Officer at 410-965-0454, or by writing to the address listed above.

1. Employee Work Activity Report—0960-0483. The data collected by the Social Security Administration on Form SSA-3033 is reviewed and evaluated to determine if the claimant meets the disability requirements of the law, when the claimant returns to work after the alleged or established onset date of disability. When a possible unsuccessful work attempt or nonspecific subsidy is involved (and the information cannot be obtained through telephone contact), Form SSA-3033 will be used to request a description, by mail, of the employee's work effort. The respondents are employers of Old Age, Survivors and Disability Insurance and Supplemental Security Income disability applicants and beneficiaries.

Number of Respondents: 12,500.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 3,125 hours.

2. 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—0960-0641.

Background

Public Law (Pub. L.) 106-170, the Ticket to Work and Work Incentives Improvement Act of 1999, created 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, which 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 TTW 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 Form 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 the 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 TTW program. The respondents are ENs under the TTW 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.

4. Statement Regarding the Inferred Death of an Individual By Reason of Continued and Unexplained Absence—0960-0002. The information collected on Form SSA-723-F4 is needed to determine if SSA may presume that a missing wage earner is dead and, if so, to establish a date of presumed death. The respondents are people who have knowledge of the disappearance of the wage earner.

Number of Respondents: 3,000.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 1,500 hours.

II. 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 package by calling the SSA Reports Clearance Officer on [phone], or by writing to the address listed above.

1. Information Collections Conducted by State Disability Determination Services (DDS) on Behalf of SSA—0960-0555. The State DDS's collect certain information to administer SSA's disability program. The information collected is as follows: (1) Medical evidence of record (MER)—DDS's use MER information to determine a person's physical and/or mental status prior to making a disability determination; (2) consultative exam (CE) medical evidence—DDS's use CE medical evidence to make disability determinations when the claimant's own medical sources cannot or will not provide the information; (3) CE claimant forms—The DDS's request that claimants complete an authorization form for the release of consultative exam information to a personal physician and to complete an appointment form to confirm scheduled CE appointments; (4) CE provider information—DDS's use the CE provider information to verify medical providers' credentials and licenses before hiring them to conduct CEs; (5) activities of daily living (ADL)—this information and other medical evidence are part of the evidentiary documentation used by the DDS's in evaluating a person's disability; and (6) pain information—this information is used by the DDS's to assess the effects of symptoms on functioning for determining disability. The respondents are medical providers, other sources of MER and disability claimants.

(1) MER (respondents-medical providers and other sources)

Number of Responses: 6,052,494.

Frequency of Response: Unknown.

Average Burden Per Response: 15 minutes.

Estimate Annual Burden: 1,513,124.

(2) CE Medical Evidence (respondents-medical providers)

Number of Responses: 1,640,269.

Frequency of Response: Unknown.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 820,135 hours.

(3) CE Forms (respondents-claimants)

	Appointment form	Medical release
Number of Respondents	820,134	1,640,269.
Frequency of Response	1	1.
Average Burden Per Response	5 minutes	5 minutes.
Estimated Annual Burden	68,345 hours	136,689 hours.

(4) CE Providers (respondents-medical providers)

Number of Responses: 3,000.

Frequency of Response: 1.

Average Burden: 20 minutes.

Estimated Annual Burden: 1,000 hours.

(5) ADL (respondents-claimants)

Number of Responses: 2,000,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 500,000 hours.

(6) Pain (respondents-claimants)

Number of Responses: 1,000,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Average Burden: 250,000 hours.

2. Application for U.S. Benefits Under the Canada-U.S. International Agreement—0960-0371. The information collected on Form SSA-1294 is used to determine entitlement to benefits. The respondents are individuals who live in Canada and file for U.S. Social Security benefits.

Number of Respondents: 1,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 250 hours.

3. Statement of Death by Funeral Director—0960-0142. The Social Security Administration (SSA) uses the information on form SSA-721 to make timely and accurate decisions based on a report of death. The respondents are funeral directors with knowledge of the fact of death.

Number of Respondents: 1,059,400.

Frequency of Response: 1.

Average Burden Per Response: 4 minutes.

Estimated Annual Burden: 70,627 hours.

4. Statement Regarding Marriage—0960-0017. Form SSA-753 elicits information from third parties to verify the applicant's statements about intent, cohabitation, and holding out to the public as being married, which are the basic tenets of a common-law marriage. The responses are used by SSA to determine if a valid marital relationship exists and to make an accurate determination regarding entitlement to spouse/widow(er) benefits. The respondents are individuals who are familiar with and can provide confirmation of an applicant's common-law marriage.

Number of Respondents: 40,000.

Frequency of Response: 1.

Average Burden Per Response: 9 minutes.

Estimated Annual Burden: 6,000.

5. Quarterly Statistical Report on Recipients and Payments Under State-Administered Assistance Programs for Aged, Blind, and Disabled (Individuals and Couples) Recipients—0960-0130. The information collected by SSA on Form SSA-9741 is used by States to provide statistical data on recipients and assistance payments under the SSI State-administered State Supplementation Programs. The data are needed to complement information available for the programs administered by SSA and to fully explain the impact of the public income support programs on the needy, aged, blind, and disabled. SSA personnel request data about State-administered supplementation programs to compare various State programs, to examine the relationship of State supplementation expenditures and caseloads to federally-financed programs such as Medicaid, and to determine the effect of changes in SSI and other Federal programs on State supplementation programs. The respondents are State agencies who administer supplementary payment programs under SSI.

Number of Respondents: 30.

Frequency of Response: 4.

Average Burden Per Response: 60 minutes.

Estimated Annual Burden: 120 hours.

Dated: January 28, 2002.

Elizabeth A. Davidson,

Acting Reports Clearance Officer, Social Security Administration.