2017-06025. 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 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. This notice includes revisions 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 ways to minimize 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 SSA Reports Clearance Officer at the following addresses or fax numbers.

(OMB), Office of Management and Budget, Attn: Desk Officer for SSA, Fax: [phone], Email address: [e-mail]

(SSA), Social Security Administration, OLCA, Attn: Reports Clearance Director, 3100 West High Rise, 6401 Security Blvd., Baltimore, MD 21235, Fax: [phone], Email address: [e-mail]

Or you may submit your comments online through www.regulations.gov,, referencing Docket ID Number [SSA-2017-0013].

I. The information collections below are pending at SSA. SSA will submit them to OMB within 60 days from the date of this notice. To be sure we consider your comments, we must receive them no later than May 30, 2017. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Request for Waiver of Overpayment Recovery or Change in Repayment Notice—20 CFR 404.502-404.513, 404.515, 416.550-416.570, and 416.572—0960-0037. When Social Security beneficiaries and Supplemental Security Income (SSI) recipients receive an overpayment, they must return the extra money. These beneficiaries and recipients can use Form SSA-632-BK to take one of three actions: (1) Request an exemption from repaying, as recovery of the payment would cause financial hardship; (2) inform SSA they want to repay the overpayment at a monthly rate over a period longer than 36 months; or (3) request a different rate of recovery. In the latter two cases, the respondents must also provide financial information to help the agency determine how much the overpaid person can afford to repay each month. Respondents are overpaid beneficiaries or SSI recipients who are requesting: (1) A waiver of recovery of an overpayment, or (2) a lesser rate of withholding.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
Waiver of Overpayment (Completes Whole Paper Form)	400,000	1	120	800,000
Change in Repayment (Completes Partial Paper Form)	100,000	1	45	75,000
Regional Application (New York Debt Management)	44,000	1	120	88,000
Internet Instructions	500,000	1	5	41,667
Totals	1,044,000			1,004,667

2. RS/DI Quality Review Case Analysis: Sampled Number Holder; Auxiliaries/Survivors; Parent; and Stewardship Annual Earnings Test—0960-0189. Section 205(a) of the Social Security Act (Act) authorizes the Commissioner of SSA to conduct the quality review process, which entails collecting information related to the accuracy of payments made under the Old-Age, Survivors, and Disability Insurance Program (OASDI). Sections 228(a)(3), 1614(a)(1)(B), and 1836(2) of the Act require a determination of the citizenship or alien status of the beneficiary; this is only one item that we might question as part of the Annual Quality review. SSA uses Forms SSA-2930, SSA-2931, and SSA-2932 to establish a national payment accuracy rate for all cases in payment status, and to serve as a source of information regarding problem areas in the Retirement Survivors Insurance (RSI) and Disability Insurance (DI) programs. We also use the information to measure the accuracy rate for newly adjudicated RSI or DI cases. SSA uses Form SSA-4659 to evaluate the effectiveness of the annual earnings test, and to use the results in developing ongoing improvements in the process. About twenty-five percent of respondents will have in-person reviews and receive one of the following appointment letters: (1) SSA-L8550-U3 (Appointment Letter—Sample Individual); (2) SSA-L8551-U3 (Appointment Letter—Sample Family); or (3) the SSA-L8552-U3 (Appointment Letter—Rep Payee). Seventy-five percent of respondents will receive a notice for a telephone review using the SSA-L8553-U3 (Beneficiary Telephone Contact) or the SSA-L8554-U3 (Rep Payee Telephone Contact). To help the beneficiary prepare for the interview, we include three forms with each notice: (1) SSA-85 (Information Needed to Review Your Social Security Claim) lists the information the beneficiary will need to gather for the interview; (2) SSA-2935 (Authorization to the Social Security Administration to Obtain Personal Information) verifies the beneficiary's correct payment amount, if necessary; and (3) SSA-8552 (Interview Confirmation) confirms or reschedules the interview if necessary. The respondents are a statistically valid sample of all OASDI beneficiaries in current pay status or their representative payees.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-2930	1,500	1	30	750
SSA-2931	850	1	30	425
SSA-4659	325	1	10	54
SSA-L8550-U3	385	1	5	32
SSA-L8551-U3	95	1	5	8
SSA-L8552-U3	35	1	5	3
SSA-L8553-U3	4970	1	5	414
SSA-L8554-U3	705	1	5	59
SSA-8552	2350	1	5	196
SSA-85	3850	1	5	321
SSA-2935	2350	1	5	196
SSA-8510 (also saved under OMB No. 0960-0707)	800	1	5	67
Totals	17,700			2,525

3. Electronic Records Express—20 CFR 404.1512 and 416.912—0960-0753. Electronic Records Express (ERE) is a Web-based SSA program which allows medical and educational providers to electronically submit disability claimant data to SSA. Both medical providers and other third parties with connections to disability applicants or recipients (e.g., teachers and school administrators for child disability applicants) use this system once they complete the registration process. SSA employees and State agency employees request the medical and educational records collected through the ERE Web site. The agency uses the information collected through ERE to make a determination on an Application for Benefits. We also use the ERE Web site to order and receive consultative examinations when we are unable to collect enough medical records to determine disability findings. The respondents are medical providers who evaluate or treat disability claimants or recipients, and other third parties with connections to disability applicants or recipients (e.g., teachers and school administrators for child disability applicants), who voluntarily choose to use ERE for submitting information.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
ERE	5,376,998	1	10	896,166

II. SSA submitted the information collections below to OMB for clearance. Your comments regarding these information collections would be most useful if OMB and SSA receive them 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than April 27, 2017. Individuals can obtain copies of the OMB clearance packages by writing to [e-mail].

1. State Mental Institution Policy Review Booklet—20 CFR 404.2035, 404.2065, 416.635, & 416.665—0960-0110. SSA uses Form SSA-9584-BK: (1) To determine if the policies and practices of a state mental institution acting as a representative payee for SSA beneficiaries conform to SSA's regulations in the use of benefits; (2) to confirm institutions are performing other duties and responsibilities required of representative payees; and (3) as the basis for conducting onsite reviews of the institutions and preparing subsequent reports of findings. The respondents are state mental institutions serving as representative payees for Social Security beneficiaries and SSI recipients.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-9584-BK	69	1	60	69

2. Statement of Death by Funeral Director—20 CFR 404.715 and 404.720—0960-0142. When an SSA-insured worker dies, the funeral director or funeral home responsible for the worker's burial or cremation completes Form SSA-721 and sends it to SSA. SSA uses this information for three purposes: (1) To establish proof of death for the insured worker; (2) to determine if the insured individual was receiving any pre-death benefits SSA needs to terminate; and (3) to ascertain which surviving family member is eligible for the lump-sum death payment or for other death benefits. The respondents are funeral directors who handled death arrangements for the insured individuals.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-721	703,638	1	4	46,909

3. Employee Identification Statement—20 CFR 404.702—0960-0473. When two or more individuals report earnings under the same Social Security Number (SSN), SSA collects information on Form SSA-4156 to credit the earnings to the correct individual and SSN. We send the SSA-4156 to the employer to: (1) Identify the employees involved; (2) resolve the discrepancy; and (3) credit the earnings to the correct SSN. The respondents are employers involved in erroneous wage reporting for an employee.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-4156	4,750	1	10	792

4. Employee Work Activity Questionnaire—20 CFR 404.1574, 404.1592—0960-0483. Social Security Disability Insurance (SSDI) beneficiaries and SSI recipients qualify for payments when a verified physical or mental impairment prevents them from working. If disability claimants attempt to return to work after receiving payments, but are unable to continue working, they submit the SSA-3033, Employee Work Activity Questionnaire, so SSA can evaluate their work attempt. SSA also uses this form to evaluate unsuccessful subsidy work and determine applicants' continuing eligibility for disability payments. The respondents are employers of SSDI beneficiaries and SSI recipients who unsuccessfully attempted to return to work.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-3033-BK	15,000	1	15	3,750

5. Request for Medical Treatment in an SSA Employee Health Facility: Patient Self-Administered or Staff Administered Care—0960-0772. SSA operates onsite Employee Health Clinics (EHC) in eight different States. These clinics provide health care for all SSA employees including treatments of personal medical conditions when authorized through a physician. Form SSA-5072 is the employee's personal physician's order form. The information we collect on Form SSA-5072 gives the nurses the guidance they need by law to perform certain medical procedures and to administer prescription medications such as allergy immunotherapy. In addition, the form allows the medical officer to determine whether they can administer treatment safely and appropriately in the SSA EHCs. Respondents are physicians of SSA employees who need to have medical treatment in an SSA EHC.

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

Modality of completion	Number of respondents	Frequency of response	Number of responses	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-5072 Annually	25	1	25	5	2
SSA-5072 Bi-Annually	75	2	150	5	13
Totals	100				15

Dated: March 22, 2017.

Naomi R. Sipple,

Reports Clearance Officer, Social Security Administration.