E7-2418. Agency Information Collection Activities: 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, the Paperwork Reduction Act of 1995, effective October 1, 1995. The information collection packages that may be included in this notice are for new information collections, approval of existing information collections, revisions to OMB-approved information collections, and extensions (no change) of OMB-approved information collections.

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. The information can be mailed, faxed or e-mailed to the individuals at the addresses and 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, DCFAM, Attn: Reports Clearance Officer, 1333 Annex Building, 6401 Security Blvd., Baltimore, MD 21235, Fax: [phone], E-mail address: [e-mail].

I. The information collections listed below are pending at SSA and 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. Application for Child's Insurance Benefits—20 CFR 404.350-404.368, 404.603, and 416.350—0960-0010. SSA uses the information collected by the SSA-4-BK to entitle children of living and deceased workers to monthly Social Security payments. Respondents are guardians completing the form on behalf of the children of living or deceased workers, or the children of living or deceased workers.

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

Number of Respondents: 1,740,000.

Estimated Annual Burden: 344,141 hours.

Type of request	Number of respondents	Frequency per response	Average burden per response (minutes)	Estimated annual burden
Life Claims	46,250	1	10	7,708
Life Claims—MCS	439,375	1	10	73,229
Life Claims—Signature Proxy	439,375	1	9	65,906
Death Claims	40,750	1	15	10,188
Death Claims—MCS	387,125	1	15	96,781
Death Claims—Signature Proxy	387,125	1	14	90,329
Totals	1,740,000			344,141

2. Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits—20 CFR 404.2015 and 416.615—0960-0024. The information collected on the SSA-787 is used to determine whether an individual is capable of handling his or her own benefits. This information is also used for leads in selecting a representative payee, if needed. The respondents are physicians of the beneficiaries or medical officers of the institution in which the beneficiaries reside.

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

Number of Respondents: 120,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 20,000 hours.

3. Modified Benefit Formula Questionnaire—Foreign Pension—0960-0561. The information collected on the SSA-308 is used to determine exactly how much (if any) of a foreign pension may be used to reduce the amount of Social Security retirement or disability benefits under the modified benefit formula. The respondents are applicants for Social Security retirement or disability benefits.

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

Number of Respondents: 50,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 8,333 hours.

4. Authorization to Release Medical Report to Physician—20 CFR 401.55 & 401.100—0960-NEW. If the claimant, his or her court appointed representative, or a parent of a minor child wants the consultative examination (CE) report sent to the claimant's treating physician, he or she will complete the information requested on Form SSA-91 and send it to SSA for processing. SSA will use the information collected to send the CE report to the authorized physician. Respondents are applicants for disability claims.

Type of Request: Collection in use without an OMB number.

Number of Respondents: 7,922.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 660 hours.

5. Claimant Travel Reimbursement Request—20 CFR 404.999a-d—0960-NEW. The claimants have the right to be reimbursed for their travel expenses to and from a consultative examination (CE). In order to be reimbursed, the claimants must submit an itemized list of what they spent to travel round trip to the CE. The SSA-104 is sent to the claimants with the CE appointment notice. If the claimants want to be reimbursed for their travel expenses, they must complete, sign and return the SSA-104 to SSA. SSA uses the information collected on this form to determine the amount of reimbursement. Respondents are applicants for disability claims.

Type of Request: Collection in use without an OMB number.

Number of Respondents: 11,092.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 1,849 hours.

6. Treating Physician Consultative Examination Interest Form—20 CFR 404.1519g-i—0960-NEW. The individual's treating physician (TP) is the preferred source to perform a consultative examination (CE). SSA uses the SSA-84 to ascertain whether the TP is interested in performing the CE. This form is sent to the claimant's treating physician along with the medical evidence of record request letter. If the treating physician is interested in performing the CE, he or she indicates interest by completing the SSA-84 and returning it to SSA. If the form is not returned, SSA assumes that the TP is not interested in performing the CE. Respondents are the claimants' treating physicians.

Type of Request: Collection in use without an OMB number.

Number of Respondents: 168.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 14 hours.

7. Electronic Records Express—0960-NEW. Electronic Records Express (ERE) is a new Internet-based platform which facilitates the electronic submission of medical and school records needed for the disability process. These records are currently mailed as hard paper copies to SSA and state Disability Determination Services (DDSs) under the aegis of OMB No. 0960-0555, the Clearance of Information Collections Conducted by State Disability Determination Services on Behalf of SSA. While SSA and the DDSs will continue to accept paper copies, ERE offers respondents the opportunity to submit these records electronically. The revised burden for the actual document submission will continue to be covered under 0960-0555; this new collection covers the ERE registration and user training process. The respondents are medical providers and school professionals who submit information to SSA on behalf of disability applicants or beneficiaries.

Type of Request: New information collection.

Number of Respondents: 20,000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 1,667 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 packages by calling the SSA Reports Clearance Officer at 410-965-0454, or by writing to the address listed above.

1. Application of Circuit Court Law—20 CFR 404.985 & 416.1458—0960-0581. Under SSA regulations, persons may request re-adjudication on the basis that the application of an acquiescence ruling (AR) would change a prior determination or decision. We will use the information provided to determine whether they are entitled to re-adjudication of their claims in accordance with these regulations. We will review the available information in the requests to determine whether the issue(s) stated in the AR pertains to the claimant's case. If re-adjudication is appropriate, we will consider only those issue(s) covered by the AR. Any new determination or decision will be subject to administrative or judicial review in accordance with our regulations. Individuals who request readjudication are claimants for Social Security benefits and Supplemental Security Income payments.

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

Number of Respondents: 10,000.

Frequency of Response: 1.

Average Burden Per Response: 17 minutes.

Estimated Annual Burden: 2,833 hours.

2. Physical Residual Functional Capacity Assessment and Mental Residual Functional Capacity Assessment—20 CFR 404.1545-404.1546 & 416.945-416.946—0960-0431. The information collected on forms SSA-4734-BK and SSA-4734-F4-SUP is needed by SSA to assist in the adjudication of disability claims involving physical and/or mental impairments. The forms assist the State DDS offices to evaluate the severity of impairments by providing standardized data collection forms. The use of these forms by the DDSs ensures nationally consistent evaluations presented in a concise, clear and readily understandable manner. The respondents are primarily doctors in DDSs funded and administered by SSA.

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

Number of Respondents: 2,397,646.

Frequency of Response: 1.

Average Burden Per Response: 20 minutes.

Estimated Annual Burden: 799,215 hours.

3. Substitution of Party Upon Death of Claimant—20 CFR 404.957(c)(4) & 416.1457(c)(4)—0960-0288. The HA-539 is used to collect information from any individual who asks to be made a substitute party for a claimant for either Social Security benefits or Supplemental Security Income payments who dies while his or her request for a hearing is pending. This information is needed and used by SSA to afford these individuals their statutory right to a hearing and decision under the Social Security Act.

Respondents are individuals requesting to proceed with hearings as substitute parties for deceased claimants for Social Security benefits or Supplemental Security Income payments.

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

Number of Respondents: 4,320.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 360 hours.

4. Child Relationship Statement—20 CFR 404.355 & 404.731—0960-0116. The information collected on the SSA-2519 is used to help determine the entitlement of children to Social Security benefits under section 216(h)(3) of the Social Security Act (deemed child provision). Respondents are persons with knowledge of the relationship between the number holder and his/her alleged biological child who is filing for benefits.

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

Number of Respondents: 50,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 12,500 hours.

5. Application for Lump Sum Death Payment—20 CFR 404.390-404.392—0960-0013. The Social Security Administration (SSA) needs the information collected on Form SSA-8-F4 to authorize payment of the lump sum death payment (LSDP) to a widow, widower, or children as defined in Section 202(i) of the Act. Respondents are applicants for LSDP.

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

Number of Respondents: 587,000.

Estimated Annual Burden: 93,187.

Collection method	Number of respondents	Estimated completion time (minutes)	Burden hours
MCS	278,825	10	46,471
MCS/Signature Proxy	278,825	9	41,824
Paper	29,350	10	4,892
Totals	587,000		93,187

6. Certificate of Support—20 CFR 404.370, 404.750, 404.408a—0960-0001. The information collected on the SSA-760-F4 is used to determine whether the parent of a deceased worker or the spouse meets the one-half support requirement specified in SSA regulations. Respondents are parents of deceased workers, or spouses who may qualify for an exception to Government Pension Offset.

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

Number of Respondents: 18,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 4,500 hours.

7. Request for Reinstatement (Title II)—20 CFR 404.1592b-404.1592f—0960-NEW. Form SSA-371 is used by former beneficiaries for Title II benefits who wish to request Expedited Reinstatement (EXR) of their Title II disability benefits. SSA uses the SSA-371 to obtain a signed statement from the individual requesting EXR, and to verify that the applicant meets the EXR requirements. The form will be maintained in the disability folder of the applicant to demonstrate that the individual was aware of the EXR requirements and chose to request EXR. Respondents are applicants for EXR of Title II disability benefits.

Type of Request: Collection in use without an OMB number.

Number of Respondents: 10,000.

Frequency of Response: 1.

Average Burden per Response: 2 minutes.

Estimated Annual Burden: 333 hours.

8. Request for Reinstatement (Title XVI)—20 CFR 416.999-416.999d—0960-NEW. Form SSA-372 is used by former SSI claimants who wish to request Expedited Reinstatement (EXR) of their Title XVI disability payments. SSA uses the SSA-372 to obtain a signed statement from the individual requesting EXR and to verify that the requestor meets the EXR requirements. The form will be maintained in the disability folder of the applicant to demonstrate that the individual was aware of the EXR requirements and chose to request EXR. Respondents are applicants for EXR of Title XVI disability payments.

Type of Request: Collection in use without an OMB number.

Number of Respondents: 2,000.

Frequency of Response: 1.

Average Burden per Response: 2 minutes.

Estimated Annual Burden: 67 hours.

9. Vendor List Registration Form—0960-NEW. SSA maintains an Employer Wage Reporting and Instructions Vendor Web site. On this site, relevant vendors are allowed to list their products and services free of charge. Vendors wishing to list their information on the site can submit these requests via a written registration form or through the Web site itself. The respondents are vendors who offer employer wage reporting services and who want SSA to list their information on the relevant Web site.

Type of Request: New information collection.

Number of Respondents: 500.

Frequency of Response: 1.

Average Burden Per Response: 8 minutes.

Estimated Annual Burden: 67 hours.

Dated: February 7, 2007.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.