04-2215. 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 and/or faxed to the individuals at the addresses and fax numbers listed below:

(OMB), Office of Management and Budget, Attn: Desk Officer for SSA, New Executive Building, Room 10235, 725 17th St., NW., Washington, DC 20503, Fax: [phone].

(SSA), Social Security Administration, DCFAM, Attn: Reports Clearance Officer, 1338 Annex Building, 6401 Security Blvd., Baltimore, MD 21235, Fax: [phone].

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 Statement for Child's Insurance Benefits—20 CFR 404.350-.368, 404.603, and 416.350—0960-0010. Title II of the Social Security Act provides for payment of monthly benefits to the children of an insured retired, disabled, or deceased worker, if certain conditions are met. The form SSA-4-BK is used by SSA to collect information needed to determine whether the child or children are entitled to benefits. The respondents are children of the worker or individuals who complete this form on their behalf.

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

	Life claims	Death claims
Number of Respondents	925,000	815,000.
Frequency of Response	1	1.
Average Burden Per Response	10.5 minutes	15.5 minutes.
Estimated Annual Burden	161,875 hours	210,542 hours.

2. Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits—20 CFR 404.2015 and 416.615—0960-0024. SSA uses the information collected on form SSA-787 to determine an individual's capability, or lack thereof, to handle his or her own benefits. This information also provides SSA with a means of selecting a representative payee, if this proves necessary. The respondents are beneficiaries' physicians.

Type of Request: Extension 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. Physical Residual Functional Capacity Assessment and Mental Residual Functional Capacity Assessment—20 CFR 404.1545 and 416.945—0960-0431. The information collected by form SSA-4734 is used in the adjudication of disability claims involving physical and/or mental impairments. The form provides the State Disability Determination Service (DDS) with a standardized data collection format to evaluate impairment(s) and to present findings in a clear, concise, and consistent manner. The respondents are State DDSs administering Title II and Title XVI disability programs.

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

	SSA-4734-BK	SSA-4734-SUP
Number of Respondents	1,625,095	796,770.
Frequency of Response	1	1.
Average Burden Per Response	20 minutes	20 minutes.
Estimated Annual Burden	541,698 hours	265,590 hours.

4. Social Security Benefits Applications—20 CFR Subpart D, 404.310-404.311 and 20 CFR Subpart F, 404.601-401.603—0960-0618. One of the requirements for obtaining Social Security benefits is the filing of an application so that a determination may be made on the applicant's eligibility for monthly benefits. In addition to the traditional paper application, SSA has developed various options for the public to add convenience and operational efficiency to the application process. The total estimated number of respondents to all application collections formats is 3,843,369 with a cumulative total of 995,457 burden hours. The respondents are applicants for RIB, DIB, and/or spouses' benefits.

Please note that burden hours for applications taken through the Modernized Claims System (MCS) are accounted for in the hardcopy collection formats. MCS is an electronic collection method that mirrors the hardcopy application formats. Guided by the MCS collection screens, an SSA representative interviews the applicant and inputs the information directly into SSA's application database. MCS offers the representative prompts based on the type of application being filed and the circumstances of the applicant. These prompts facilitate a more complete initial application, saving both the agency and applicant time. MCS also propagates identity and similar information within the application, which saves additional time.

Type of Request: Revision of an OMB-approved information collection (ISBA collection only).

Internet Social Security Benefits Application (ISBA)

ISBA, which is available through SSA's Internet site, is one method that an individual can choose to file an application for benefits. Individuals can use ISBA to apply for retirement insurance benefits (RIB), disability insurance benefits (DIB) and spouse's insurance benefits based on age. SSA gathers only information relevant to the individual applicant's circumstances and will use the information collected by ISBA to entitle individuals to RIB, DIB, and/or spouses' benefits. The respondents are applicants for RIB, DIB, and/or spouses benefits.

Number of Respondents: 169,000.

Frequency of Response: 1.

Average Burden Per Response: 21.4 minutes.

Estimated Annual Burden: 60,277 hours.

Paper Application Forms

Application for Retirement Insurance Benefits (SSA-1)

The SSA-1 is used by SSA to determine an individual's entitlement to retirement insurance benefits. In order to receive Social Security retirement insurance benefits, an individual must file an application with the SSA. The SSA-1 is one application that the Commissioner of Social Security prescribes to meet this requirement. The information that SSA collects will be used to determine entitlement to retirement benefits. The respondents are individuals who choose to apply for Social Security retirement insurance.

Number of Respondents: 1,460,692.

Frequency of Response: 1.

Average Burden Per Response: 10.5 minutes.

Estimated Annual Burden: 255,621 hours.

Application for Wife's or Husband's Insurance Benefits (SSA-2)

SSA uses the information collected on Form SSA-2 to determine if an applicant (including a divorced applicant) can be entitled to benefits as the spouse of the worker and the amount of the spouse's benefits. The respondents are applicants for wife's or husband's benefits, including those who are divorced.

Number of Respondents: 700,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 175,000 hours.

Application for Disability Insurance Benefits (SSA-16)

Form SSA-16-F6 obtains the information necessary to determine whether the provisions of the Act have been satisfied with respect to an applicant for disability benefits, and detects whether the applicant has dependents who would qualify for benefits on his or her earnings record. The information collected on form SSA-16 helps to determine eligibility for Social Security disability benefits. The respondents are applicants for Social Security disability benefits.

Number of Respondents: 1,513,677.

Frequency of Response: 1.

Average Burden Per Response: 20 minutes.

Estimated Annual Burden: 504,559 hours.

5. Youth Transition Process Demonstration Evaluation Data Collection—0960-NEW. To further the President's New Freedom Initiative goal of increasing employment for individuals with disabilities, SSA plans to award seven cooperative agreements for the purpose of developing service delivery systems to assist youth with disabilities to successfully transition from school to work. SSA is funding two coordinated contracts to provide (1) technical assistance and (2) an evaluation. SSA will work with the Evaluation Contractor to use the results to conduct a net outcome evaluation to determine the long-term effectiveness of the interventions, impacts, and benefits of the demonstration. Evaluation data will be used by the projects to improve the efficiency of the project's operations; use of staff; linkages between the project and the agencies through which comprehensive services are arranged; and specific aspects of service delivery to better meet the needs of the targeted population. This type of project is authorized by sections 1110 and 234 of the Social Security Act. The respondents will be youth with disabilities who have enrolled in this project.

Type of Request: New information collection.

Number of Respondents: 5,000.

Frequency of Response: 4.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 5,000 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. Certificate of Support—20 CFR 404.408a, 44.370, and 404.750—0960-0001. The information collected by form SSA-760-F4 is used to determine whether a deceased worker provided the one-half support required for entitlement to parent's or spouse's Social Security benefits. The information will also be used to determine whether the Government pension offset would apply to the applicant's benefit payments. The respondents are parents of deceased workers or spouses who may be subject to the Government pension offset.

Type of Request: Extension 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.

2. Notice Regarding Substitution of Party Upon Death of Claimant—20 CFR 404.957(c)(4) and 416.1457(c)(4)—0960-0288. When a claimant for Social Security or Supplemental Security Income benefits dies while a request for a hearing is pending, the hearing will be dismissed unless an eligible individual makes a written request to SSA showing that he or she would be adversely affected by the dismissal of the deceased's claim. An individual may satisfy this requirement by completing an HA-539. SSA uses the information collected to document the individual's request to be made a substitute party for a deceased claimant, and to make a decision on whom, if anyone, should become a substitute party for the deceased. The respondents are individuals requesting hearings on behalf of deceased claimants for Social Security benefits.

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

Number of Respondents: 10,548.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 879 hours.

3. Benefits Planning, Assistance, and Outreach (BPAO) Program—0960-0629.

Background

SSA awarded cooperative agreements to establish community-based benefits planning, assistance, and outreach projects in every State and U.S. Territory, as it is authorized to do under Section 1149 of the Social Security Act. Potential awardees were State and local governments, public and private organizations, and nonprofit and for-profit organizations. SSA intended to establish as many projects as needed to ensure state-wide coverage for all Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) beneficiaries nationally. The projects funded under this cooperative agreement program are part of SSA's strategy to increase the number of beneficiaries who return to work and achieve self-sufficiency as the result of delivering direct services to them. The overall goal of the program is to disseminate accurate information concerning work incentives programs and issues related to youth programs to beneficiaries with disabilities (including transition-to-work aged youth), in order to enable them to make informed choices about work.

Collection Activities

The BPAO project collects identifying information from the project sites and benefits specialists. In addition, data are collected from the beneficiaries on background, employment, training, benefits, and work incentives. We use the information to manage the program, with particular emphasis on contract administration, budgeting, and training. In addition, SSA uses the information to evaluate the efficacy of the program and to ensure that those dollars appropriated for BPAO services are being spent on SSA beneficiaries. The project data will be valuable to SSA in its analysis of and future planning for the SSDI and SSI programs.

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

Title of collection	Number of annual responses	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
Site	147	1	1.8	4.4
Specialist	422	1	1.8	12.6
Beneficiary	60,000	1	5.3	5,300
Total	60,569			5,138

Total burden hours for this request: 5,317 hours.

4. Information Collections conducted by State Disability Determination Services (DDS) on Behalf of SSA—20 CFR, Subpart P, 404.1503a, 404.1512, 404.1513, 404.1514 404.1517, 404.1519; 20 CFR Subpart Q, 404.1613, 404.1614, 404.1624; 20 CFR Subpart I, 416.903a, 416.912, 416.913, 416.914, 416.917, 416.919 and 20 CFR Subpart J, 416.1013, 416.1024, 416.1014—0960-0555. The State DDS's collect certain information to administer SSA's disability program. The information collected is as follows: (1) Medial 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; and (5) 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.

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

(1) MER (Respondents—Medical Providers and Other Sources)

Number of Responses: 6,665,907.

Frequency of Response: Unknown.

Average Burden Per Response: 15 minutes.

Estimate Annual Burden: 1,666,477.

(2) CE Medical Evidence (Respondents—Medical Providers)

Number of Responses: 1,737,152.

Frequency of Response: Unknown.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 868,576 hours.

(3) CE Forms (Respondents-Claimants)

	Appointment form	Medical release
Number of respondents	868,576	1,737,152.
Frequency of response	1	1.
Average burden per response	5	5.
Estimated annual burden	72,381 hours	144,763 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) Pain Forms (Respondents—Claimants)

Number of Responses: 1,000,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 250,000 hours.

5. I nternational Direct Deposit—31 CFR 210—0960-NEW. SSA uses the information collected on the International Direct Deposit (IDD) Form, form SSA-1199 (Country), to enroll beneficiaries residing abroad in the IDD program. There are currently 39 countries where IDD is now available, and SSA plans to expand this service to other countries as it becomes available. The SSA-1199 (Country) is named according to the country for its intended use, but will always request the same basic enrollment information. This form is a variation of the SF-1199 A, Direct Deposit Sign-Up Form, which is used to enroll a beneficiary in direct deposit to a U.S. financial institution. The respondents are beneficiaries living in a foreign country who request Direct Deposit to a financial institution in their country of residence.

Type of Request: New information collection.

Number of Respondents: 5,000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Average Burden: 417 hours.

Dated: January 28, 2004.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.