E9-3171. 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 revisions and extensions of OMB-approved Information Collections and a new 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, email, 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. Application for Search of Census Records for Proof of Age—20 CFR 404.716-0960—0097. SSA uses the information collected by the SSA-1535-U3 to provide the Census Bureau with sufficient identification information for an accurate search of census records for proof of age of an individual applying for Social Security benefits. When preferred evidence of age is not available and the available evidence is not convincing, SSA may request the U.S. Department of Commerce, Bureau of the Census, to search its records in order to establish a claimant's date of birth. The Census Bureau uses the information from 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.

Number of Respondents: 18,030.

Frequency of Response: 1.

Average Burden Per Response: 12 minutes.

Estimated Annual Burden: 3,606 hours.

2. Youth Transition Process Demonstration Evaluation Data Collection—0960-0687.

Background

The purpose of the Youth Transition Demonstration (YTD) project is to help young people with disabilities make the transition from school to work. While participating in the project, youth can continue to work and/or continue their education because SSA waives certain disability program rules and offers services to youth who are receiving disability benefits or have a high probability of receiving them. We are currently implementing YTD projects in eight sites across the country. The evaluation will produce empirical evidence on the effects of the waivers and project services including educational attainment, employment, earnings, and receipt of benefits by youth with disabilities, but also on the Social Security Trust Fund and federal income tax revenues. This project is authorized by Sections 1110 and 234 of the Social Security Act.

Project Description

Given the importance of estimating YTD effects as accurately as possible, we will evaluate the project using rigorous analytic methods based on randomly assigning youth to a treatment or control group. We will conduct several data collections. These include (1) baseline interviews with youth and their parents or guardians prior to random assignment; (2) follow-up interviews at 12 and 36 months after random assignment; (3) interviews and/or roundtable discussions with local program administrators, program supervisors, and service delivery staff; and (4) focus groups of youths, their parents, and service providers. The respondents are youths with disabilities enrolled in the project; their parents or guardians; program staff; and service providers.

Type of Request: Revision of an existing OMB Clearance.

Data collection year	Collection	Number of respondents	Responses per respondent	Average burden per response (hours)	Total response burden (hours)
2009	Baseline	1,895	1	0.55	1,042
	Informed Consent	1,895	1	0.083	157
	12 Month Follow-up	1,518	1	0.83	1,260
	In-depth Interviews	120	1	0.42	50
	Focus Group	150	1	1.5	225
	Program Staff/Service Provider	80	1	1	80
	36 Month Follow-up	364	1	0.83	302
Total 2009					3,116

3. Workers' Compensation/Public Disability Questionnaire—20 CFR 404.408—0960-0247. Section 224 of the Social Security Act provides for the reduction of disability insurance benefits (DIB) when the combination of DIB and any workers' compensation (WC) and/or certain federal, state or local public disability benefits (PDB) exceeds 80% of the worker's pre-disability earnings. SSA uses Form SSA-546 to collect the data necessary to determine if the worker's receipt of WC/PDB payments will cause a reduction of DIB. The respondents are applicants for the Title II DIB.

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

Number of Respondents: 100,000.

Frequency of Response: 1.

Average Burden per Response: 15 minutes.

Estimated Annual Burden: 25,000 hours.

4. Statement of Funds You Provided to Another and Statement of Funds You Received—20 CFR 416.1103(f)—0960-0481. Forms SSA-2854 and SSA-2855 collect information on an SSI beneficiary's allegations that he or she borrowed funds informally from non-commercial lender, e.g. a relative or friend. The borrower/beneficiary and the lender of the funds complete these statements. Forms SSA-2854 and SSA-2855 are required to determine whether the proceeds from the transaction are income to the borrower. If the transaction constitutes a bona fide loan, then the proceeds are not income to the borrower. Form SSA-2855 (Statement of Funds You Received) requests information from the SSI applicant/recipient by personal interview. Form SSA-2854 (Statement of Funds You Provided to Another) requests information by mail from the other party to the transaction. The respondents are SSI recipients who informally borrow money and those persons who lend the funds.

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

Number of Respondents: 40,000.

Frequency of Response: 1.

Average Burden per Response: 10 minutes.

Estimated Annual Burden: 6,667 hours.

5. The Mental Health Treatment Study (MHTS)—0960-0726.

Background

Because of advances in medical treatment, assistive devices, changes in the way we view those with disabilities, and legislation designed to assure access to employment, SSA is taking on an increasingly active role in assisting Social Security disability beneficiaries who want to return to work. As a result, SSA developed the MHTS under Section 234 of the Social Security Act (42 U.S.C. 434), which gives the Commissioner of Social Security the authority to carry out experiments and demonstration projects designed to determine the relative advantages and disadvantages of interventions that facilitate a beneficiary's return to work. Part of the agency's role involves finding ways to promote work and increase independence among disability beneficiaries.

SSA received additional support for this study in February 2001, through President Bush's New Freedom Initiative—a comprehensive program whose primary goal is to promote the full participation of individuals with disabilities in all areas of society. The aim of the Initiative is to help Americans with disabilities by increasing their access to effective technologies, expanding educational opportunities, increasing the ability of Americans with disabilities to integrate into the workforce, and promoting increased access into daily community life. This initiative provided SSA with the support that will enable beneficiaries to maximize their self-sufficiency and potentially enter or reenter the workforce.

MHTS Collection

The MHTS implemented a randomized trial study designed to evaluate the effect of the intervention on employment and functional outcomes for SSDI beneficiaries with a primary mental impairment of schizophrenia or affective disorder. SSA is currently implementing the MHTS in 22 demonstration sites across the United States, with one site having two locations. The study participants are SSDI beneficiaries with varying clinical and demographic characteristics, employment histories, and, sometimes, additional medical impairments. The study design has two arms: treatment (special services), and control (regular services) groups. SSA randomly assigned study participants to the treatment or control group. Each treatment or control recipient will participate for a total of 24 months following enrollment. The treatment intervention activities include the following: diagnostic psychiatric assessment, comprehensive medical assessment, systematic medication management, supporting employment, individualized clinical treatment, supplemental health insurance, coordination and payment of recipients' claims, as well as quality assurance mechanisms and adherence to treatment guidelines, with subsequent training to improve deficiencies as identified.

The comprehensive assessment of the MHTS outcomes will identify which, if any, of the interventions resulted in successful employment and functioning outcomes, and identify the characteristics of the interventions that contributed to the success. This information enables SSA to develop better ways to improve services to current and future recipients. SSA also uses this information to guide any potential changes to program rules to allow for better coordination among other federal and state programs.

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

Screener Estimated Burden

Questionnaire	Frequency of response	Number of respondents	Burden per responses (minutes)	Total burden hours
Screener Survey	1	2,265	4	151

Estimated Burden for Treatment Group

Questionnaire	Frequency of response	Total number of respondents1	Hours per response (minutes)	Total burden hours
Baseline	1	1,121	47	878
Quarterly	7	1,121	18	2,354
Follow-up	1	1,121	30	561
Total				3,793
1 The number of respondents may reduce over time due to study withdrawals.

Estimated Burden for Control Group

Questionnaire	Frequency of response	Total number of respondents	Hours per response (minutes)	Total burden hours
Baseline	1	1,117	47 minutes	875
Quarterly	7	1,117	7 minutes	912
Follow-up	1	1,117	30 minutes	559
Total				2,346

Total Estimated Burden for All Study Activities

Questionnaire	Frequency of response	Total number of respondents	Total burden hours
Screener Survey	1	2,265	151
Treatment Group	9	1,121	3,792
Control Group	9	1,117	2,345
Total		4,503	6,288

6. Application for SSA Employee Testimony—20 CFR 403.100-155—0960-0619. SSA regulations at 20 CFR 403.100-155 establish policies and procedures whereby an individual, organization, or governmental entity may request official agency information, records, or testimony of an agency employee in a legal proceeding where the agency is not a party. The request, which must be in writing to the Commissioner, must fully set out the nature and relevance of the sought testimony. Respondents are individuals or entities who request testimony from SSA employees in a legal proceeding.

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

Number of Respondents: 100.

Frequency of Response: 1.

Average Burden Per Response: 60 minutes.

Estimated Annual Burden: 100 hours.

7. Self-Employment/Corporate Officer Questionnaire—20 CFR 404.435(e), 404.446—0960-0487. SSA uses Form SSA-4184 to develop earnings and corroborate the claimant's allegations of retirement when the claimant is self-employed or a corporate officer. SSA uses the information to determine an individual's Old Age, Survivors, and Disability Insurance (OASDI) benefit amount. The respondents are self-employed individuals or corporate officers who apply for OASDI benefits.

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

Number of Respondents: 50,000.

Frequency of Response: 1.

Average Burden Per Response: 20 minutes.

Estimated Annual Burden: 16,667 hours.

8. Claimant's Medication—20 CFR 404.1512, 416.912—0960-0289. In cases where a claimant is requesting a hearing after denial of his or her claim for Social Security benefits, SSA uses Form HA-4632 to request information from the claimant regarding the medications they are using. This information helps the Administrative Law Judge (ALJ) hearing the case to inquire fully into the medical treatment the claimant is receiving and the effect of medications on the claimant's medical impairments and functional capacity. Respondents are applicants for OASDI benefits and/or Supplemental Security Income (SSI) payments.

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

Number of Respondents: 200,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 50,000 hours.

9. Request for Withdrawal of Application—20 CFR 404.640—0960-0015. Individuals complete Form SSA-521 to request withdrawal of an application for benefits. Individuals who wish to withdraw their applications for benefits complete this form. SSA uses the information from Form SSA-521 to process the request for withdrawal. The respondents are applicants for OASDI benefits.

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

Number of Respondents: 100,000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 8,333 hours.

10. Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare Low-Income Subsidy)—0960-0729. Under the aegis of the Medicare Modernization Act of 2003, Medicare beneficiaries can apply for a subsidy for the Medicare Prescription Drug Plan (Part D) program. In some cases, SSA will need to verify the details of applicants' accounts at financial institutions to determine if they are eligible for the subsidy. Form SSA-4640 will give SSA the authority to contact financial institutions about applicants' accounts. Financial institutions will also use the form to verify the information requested by SSA. The respondents are applicants for the Medicare Part D program subsidy and financial institutions where applicants have accounts.

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

	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
Medicare Part D Subsidy Applicants	5,000	1	1	84
Financial Institutions	5,000	1	5	333
Totals	10,000			417

11. Request to Pay Civil Monetary Penalty by Installment Agreement—20 CFR 498—0960-NEW. SSA uses Form SSA-640 to obtain the information necessary to determine a repayment rate for individuals who have a civil monetary penalty imposed on them for various fraudulent conduct related to SSA-administered programs. SSA needs this financial information to ensure the repayment rate is in the best interest of both the individual and the agency. The respondents are recipients of Social Security benefits and non-entitled individuals who must pay a civil monetary penalty.

Type of Request: New information collection.

Number of Respondents: 400.

Frequency of Response: 1.

Average Burden Per Response: 120 minutes.

Estimated Annual Burden: 800 hours.

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. Report of New Information in Disability Cases—20 CFR 404.1588—0960-0071. SSA uses the information it collects on Form SSA-612 to ensure federal Old Age, Survivors, and Disability Insurance (OASDI) payments are correct. It is essential beneficiaries notify SSA of any information that may affect their continuing entitlement to disability benefits. To facilitate and encourage timely reporting of such events, SSA furnishes beneficiaries a Form SSA-612. The beneficiary completes and returns the form to SSA when there is a change in his/her circumstances. When a beneficiary reports a change, SSA investigates any reported work activity or improvement in the beneficiary's condition, updates its records, and makes necessary payment changes. The respondents are recipients of federal OASDI benefits.

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

Number of Respondents: 27,000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 2,250 hours.

Note:

This is a correction notice: SSA inadvertently published the incorrect burden information for this collection on December 02, 2008. We are correcting this error here. Previously, SSA published this collection as an extension; however, as we are revising the Privacy Act Statement, this is now a revision.

2. Statement of Marital Relationship (By one of the parties)—20 CFR 404.726—0960-0038. Where no formal marriage documentation exists, SSA uses the information it collects on Form SSA-754-F4 to determine whether an individual applying for spousal benefits meets the criteria of common-law marriage under state law. The respondents are applicants for spouse's Social Security benefits or SSI payments. Note: SSA listed this information collection as an extension of an OMB-approved information collection in the 60-Day Federal Register Notice published on October 27, 2008; it is a revision of an OMB-approved information collection.

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

Number of Respondents: 30,000.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 15,000 hours.

3. Application for Parent's Insurance Benefits—20 CFR 404.370-404.374, 20 CFR 404.601-404.603—0960-0012. SSA uses Form SSA-7 to collect information used to entitle an individual to his or her parent's OASDI benefits. The respondents are claimants who wish to apply to receive their parent's OASDI 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. 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. An individual may request waiver of recovery of an overpayment or a different repayment rate of OASDI benefits and SSI payments. To make this request, the overpaid individual uses the SSA-632-BK. The individual explains why he/she is 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, he/she can use the SSA-632-BK to request a monthly rate or to request a different rate of recovery. In those cases, the individual 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.

Type of request	Number of respondents	Frequency of response	Average burden per response	Total annual burden
Waiver of Overpayment (Completes Whole Form)	400,000	1	2 hours	800,000
Change in Repayment (Completes Partial Form)	100,000	1	45 minutes	75,000
Internet Instructions	500,000	1	5 minutes	41,667
Totals	1,000,000			916,667

5. You Can Make Your Payment by Credit Card—0960-0462. SSA uses the information on Forms SSA-4588 and SSA-4589 to update an individual's Social Security record to reflect payments made on their overpayment and to effect payment through the appropriate credit card company. SSA is modifying the Form SSA-4588 to include a recurring credit card payment option to allow individuals to authorize automatic monthly payments. SSA sends out the SSA-4588 with initial overpayment notices informing individuals SSA has detected an overpayment. Individuals may choose to make a one-time payment or recurring monthly payments by completing and submitting the SSA-4588.

SSA uses the Form SSA—4589 only when individuals choose to call the program service centers to make payments in lieu of completing the Form SSA-4588. An SSA debtor contact representative completes Form SSA-4589 when a debtor calls to make a payment by telephone. The debtor contact representative also uses the information from Form SSA-4589 to make recurring monthly payments via telephone call with the debtor. Respondents are OASDI beneficiaries and SSI recipients who have outstanding overpayments.

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

Form #	Number of respondents	Frequency of response	Average burden per response (minutes)	Total burden hours
SSA-4588	3,500	1	10	583
SSA-4589	36,500	1	5	3,042
Totals	40,000			3,625

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. SSA uses the Forms HA-1151 and HA-1152 to collect data SSA needs to determine the residual functional capacity (RFC) of individuals who are appealing denied claims for benefits based on disability. SSA uses the RFC when the agency cannot make a determination on a claim for benefits based on current work activity or on medical facts alone. The respondents are medical sources paid by SSA to provide reports either based on existing medical evidence or on consultative examinations conducted for the purposes of the report. Note: SSA listed this as an extension of an OMB-approved information collection in the 60-Day Federal Register Notice published on October 27, 2008; it is a revision of an OMB-approved collection.

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

Number of Respondents: 10,000.

Frequency of Response: 20.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 50,000 hours.

7. 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's field offices use Form SSA-821-BK to obtain work information from recipients during the continuing disability review process, and whenever a work issue arises in SSI claims. SSA's processing centers and 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 substantial gainful activity. SSA will review and evaluate the data to determine if the recipient continues to meet the disability requirements of the law. The respondents are Social Security disability applicants, beneficiaries, and SSI applicants. Note: SSA listed this information collection as an extension of an OMB-approved information collection in the 60-Day Federal Register Notice published on December 11, 2008; it is a revision of an OMB-approved information collection.

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

Number of Respondents: 300,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 50,000 hours.

8. 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 payments. SSA employees secure this information during interviews conducted with members of the public who wish to file for SSI payments. SSA uses this form for two purposes: (1) To establish a disability claim, but defer the complete development of non-medical issues until SSA approves the disability, or (2) to formally deny SSI payments for non-medical reasons when information provided by the applicant results in ineligibility. The respondents are applicants for SSI payments.

Note:

SSA listed this information collection as an extension of an OMB-approved information collection in the 60-Day Federal Register Notice published on December 11, 2008; it is a revision of an OMB-approved information collection.

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

Form type	Number of respondents	Number 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

9. 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 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.

10. Claimant's Recent Medical Treatment— 20 CFR 404.1512 and 416.912—0960-0292. Each claimant who requests a hearing before an ALJ has a right to such a hearing once the Disability Determination Service (DDS), at the reconsideration level, has denied the claim. For the hearing, SSA requests the claimant complete and return the HA-4631 if the claimant's file does not reflect a current, complete medical history as the claimant proceeds through the appeals process. ALJs must obtain the information to update and complete the record and to verify the accuracy of the information. It is by this process ALJs can ascertain whether the claimant's situation has changed. The ALJ and hearing office staff use the response to make arrangements for consultative examination(s) and the attendance of an expert witness(es) at the hearing, if appropriate. During 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 claimants requesting hearings on entitlement to OASDI benefits or SSI payments.

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.

Dated: February 9, 2009.

John Biles,

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