03-9085. 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 effective October 1, 1995, The Paperwork Reduction Act of 1995. The information collection packages that may be included in this notice are for new 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 Office Building, Room 10235, 725 17th St., NW., Washington, DC 20503, Fax: [phone].

(SSA), Social Security Administration, DCFAM, Attn: Reports Clearance Officer, 1300 Annex Bldg., 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. Employee Work Activity Questionnaire—20 CFR, Subpart P, 404.1574 and .1592—0960-0483. Form SSA-3033 is used 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, Form SSA-3033 will be used to request a description of the employee's work effort. The respondents are employers of Old-Age and Survivors Disability Insurance (OASDI) and Supplemental Security Income (SSI) disability applicants and beneficiaries.

Type of Request: Extension of an OMB-approved Information Collection.

Number of Respondents: 15,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 3,750 hours.

2. Request for Internet Services Representative Payee Report—20 CFR 401.45—0960-0668.

Background

SSA is testing the Internet Representative Payee Report form (I623) that electronically reports on the use of benefit payments made on behalf of Social Security beneficiaries and SSI recipients. In support of this process, a proof of concept (POC) test limited to 40 organizational representative payees use the I623 to complete and file the representative payee report instead of using the paper SSA-623. Initially SSA projected a 6-month POC test, but is planning to expand the POC to a full operational year.

The Collection

Organizations participating in the POC will designate up to three employees that will be authenticated using SSA's existing Integrated Registration for Employers and Submitters (IRES) OMB control number 0960-0626. Once authenticated, the employee will be required to enter a Personal Identification Number (PIN) and Password to gain access to the online I623 application. The PIN and Password will serve as the electronic signature. SSA will use the information collected through the I623 to determine whether the payments provided to the representative payee have been used for the beneficiary's current maintenance and personal needs and whether the representative payee continues to be concerned with the beneficiary's welfare. The respondents are organizational representative payees designated to receive funds on behalf of Social Security beneficiaries and/or SSI recipients.

Type of request: Extension of an OMB-approved Information Collection.

Number of Respondents: 40 organizations.

Frequency of Response: 117.5 per respondent.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 1,175 hours.

3. Statement of Claimant or Other Person—0960-0045. In special situations, when there is no standard form or questionnaire, Form SSA-795 is used by SSA to obtain information from claimants or other persons having knowledge of facts in connection with many aspects of the Social Security or SSI programs. The information requested on form SSA-795 must be of sufficient importance that a signed statement, including a penalty clause, is necessary. The information collected is used to process such issues as claims for benefits or continuing eligibility, benefit amount, insured status, use of funds by a representative payee or a myriad of other program-related matters. The most typical respondents are applicants for Social Security or SSI benefits or beneficiaries of these programs. However, respondents could also include friends and relatives of the involved parties, coworkers, neighbors, or anyone else in a position to provide information pertinent to the issue(s).

Number of Respondents: 305,500.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 76,375 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 at 410-965-0454, or by writing to the address listed above.

1. Claimant's Medications—20 CFR, Subpart P, 404.1512 and Subpart I, 416.912—0960-0289. The information on Form HA-4632 is used to process title II and title XVI disability claims. Claimants provide an updated list of medications using form HA-4632. This information enables the Administrative Law Judge who conducts the hearing to fully inquire into medical treatment the claimant is receiving and the effect of medications on the claimant?s medical treatment. The respondents are applicants for title II and title XVI benefits.

Type of Request: Extension of an OMB-approved Information Collection.

Number of Respondents: 171,939.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 42,985 hours.

2. Letter to Employer Requesting Wage Information—0960-0138. Form SSA—L4201-U2 is used to collect wage data from employers to establish and/or verify wage information for SSI claimants, beneficiaries and deemors. SSA uses the data to determine if an individual is eligible for SSI and, if so, to determine the amount of the payment due. The respondents are employers of applicants for and recipients of SSI payments.

Type of Request: Extension of an OMB-approved Information Collection.

Number of Respondents: 133,000.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 66,500 hours.

Dated: April 8, 2003.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.