03-13532. 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, 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 Office Building, Room 10235, 725 17th St., NW., Washington, DC 20503, Fax: [phone].

(SSA), Social Security Administration, DCFAM, Attn: Reports Clearance Officer, 1338 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. Certification by Religious Group—20 CFR, Subpart K, 404.1075-0960-0093. The data collected on Form SSA-1458 will be used to determine if a religious group meets the qualifications set out in Section 1402(g) of the Internal Revenue Code, which permits its members to be exempt from the payment of self-employment taxes. The respondents are spokespersons for a religious group or sect.

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

Number of Respondents: 180.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 45 hours.

2. Statement of Care and Responsibility for Beneficiary—20 CFR, Subpart U, 404.2020-.2025 & Subpart F, 416.620-.625—0960-0109. Form SSA-788 is used to obtain information from the beneficiary's custodian about the representative payee applicant's concern and responsibility for the beneficiary. The respondents are individuals who have custody of a beneficiary, where someone else has filed to be the beneficiary's payee.

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

Number of Respondents: 130,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 21,667 hours.

3. Request for Reconsideration—Disability Cessation—20 CFR, Subpart J, 404.909 & Subpart N, 416.1409—0960-0349. Form SSA-789 is used by SSA to schedule disability hearings and to develop additional evidence/information for claimants whose disability is found to have ceased, not to have existed, or to no longer be disabling. The information will also be used to determine if an interpreter is needed for the disability hearing. The respondents are claimants under Title II & XVI of the Social Security Act who wish to request reconsideration of disability cessation.

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

Number of Respondents: 49,000.

Frequency of Response: 1.

Average Burden Per Response: 10—13.5 minutes.

Estimated Annual Burden: 10,045 hours.

4. Psychiatric Review Technique—20 CFR, Subpart P, 404.1520(a) Subpart I 416.920(a)-0960-0413. Form SSA-2506-BK assists the Disability Determination Services (DDS) in evaluating mental impairments by helping to (1) identify the need for additional evidence for impairment severity; (2) consider aspects of the mental impairment relevant to the individual's ability to perform work-related mental functions, and (3) organize and present the findings in a clear, concise and consistent manner. The respondents are 54 State DDSs administering Title II and title XVI disability programs.

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

Number of Responses: 1,253,703.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 313,426 hours.

5. Request for Reconsideration—20 CFR, Subpart J, 404.907-.921 and Subpart N, 416.1407-.1421—0960-0622. The information collected on Form SSA-561 is used by SSA to document and initiate the reconsideration process for determining entitlement to Social Security benefits (Title II), Supplemental Security Income payments (Title XVI), and Special Veterans benefits (Title VIII). The respondents are individuals filing for such reconsideration.

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

Number of Respondents: 1,455,000.

Frequency of Response: 1.

Average Burden Per Response: 8 minutes.

Estimated Annual Burden: 194,000 hours.

6. Request for Withdrawal of Application—20 CFR, Subpart E, 404.460—0960-0015. Form SSA-521 is completed by SSA when an individual wishes to withdraw his or her application for Social Security benefits. The respondents are individuals who wish to withdraw their applications for benefits.

Type of Request: Extension 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.

7. Collection of SSI Overpayments from Special Benefits for Certain WWII Veterans; 20 CFR, Subpart E, 416.570 & .572.—0960-0653. The information collection requirement in 20 CFR 416.570 allows for an individual to request to withhold a title XVI overpayment from Title II/VIII benefits. The information collection requirement in 20 CFR 416.572 allows for an individual to elect a higher or lower rate of withholding for recovery of an SSI overpayment. The information collected will be used to determine the proper rate of withholding of benefits to recover program overpayments. The respondents are Title II or Title VIII beneficiaries who were overpaid title XVI benefits and who request a higher rate of recovery than specified in 20 CFR 416.571.

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

Number of Respondents: 2,500.

Frequency of Response: 1.

Average Burden Per Response: 1 hour.

Estimated Annual Burden: 2,500 hours.

8. Medical or Psychological Consultant's Review of Childhood Disability Evaluation Form—20 CFR, Subpart J, 416.1040, .1043, .1045—0960-NEW. Form SSA-536 is used by SSA medical or psychological consultants to document their review and assessment of the Childhood Disability Evaluation Form, SSA-538, prepared by State DDS employees. A childhood disability evaluation is required in each SSI childhood disability case. Therefore, the consultants must prepare an assessment form SSA-536 for each childhood disability case that is reviewed. The respondents are 256 SSA medical and psychological consultants.

Type of Request: Approval of an existing information collection.

Number of Responses: 17,000.

Frequency of Response: 1.

Average Burden Per Response: 12 minutes.

Estimated Annual Burden: 3,400 hours.

9. Individuals or Agents Seeking Information or Testimony in Non-Social Security Administration Cases—20 CFR 403.120—0960-0619. 20 CFR 403.120 establishes a procedure whereby an individual, organization or governmental entity may request testimony of an agency employee in a legal proceeding to which the agency is not a party. The request, which must be in writing to the Commissioner, must fully explain the nature and the relevance of the sought testimony and include the time, date, and place where the testimony will be given. Respondents are individuals or their representatives who require testimony from Social Security Administration employees in a legal proceeding to which the Social Security Administration is not a party.

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

Number of Respondents: 40.

Frequency of Response: 1.

Average Burden Per Response: 60 minutes.

Estimated Annual Burden: 40 hours.

10. Medical Consultant's Review of Mental Functional Capacity Assessment—20 CFR, Subpart O, 404.1520(a); Subpart Q, 404.1640, 404.1643, 404.1645; and Subpart I 416.920(a)—0960-NEW. Form SSA-392-SUP is used by SSA's medical/psychological consultants to document their review and assessment of the Mental Residual Functional Capacity Form or SSA 4734-F4-SUP. The SSA-392-SUP documents whether the reviewer agrees or disagrees with the manner in which the SSA 4734-F4-SUP was completed. The SSA 392-SUP is required for each SSA 4734-F4-SUP form completed. The respondents are the 256 SSA medical/psychological consultants.

Type of Request: Approval of an existing information collection.

Number of Responses: 45,000.

Frequency of Response: 1.

Average Burden Per Response: 12 minutes.

Estimated Annual Burden: 9,000 hours.

11. Medical Consultant's Review of Physical Functional Capacity Assessment; 20 CFR Subpart O 404.1520(a), Subpart Q 404.1640, 404.1645, 404.1643, and 416.920(a), Subpart I—0960-NEW. SSA-392 is used by SSA's medical consultants to document their review and assessment of the Physical Residual Functional Capacity Form, the SSA-4734, prepared by State DDS offices. The SSA-392 is required for each SSA-4734 form completed. The respondents are the 256 SSA medical consultants.

Type of Request: Approval of an Existing Information

Collection.

Number of Responses: 92,000.

Frequency of Response: 1.

Average Burden Per Response: 12 minutes.

Estimated Annual Burden: 18,400 hours.

12. Medical Consultant's Review of Psychiatric Review Technique; 20 CFR Subpart O 404.1520(a), Subpart Q 404.1640, 404.1643, 404.1645—0960-NEW. SSA measures the performance of DDSs in the area of quality of documentation and determinations on claims. In mental claims, a Psychiatric Review Technique Form (PRTF) is completed by DDS employees. SSA medical/psychological consultants use Form SSA-3023 to document their review and assessment of the information on the PRTF. The SSA consultant completes an SSA-3023 for each PRTF in the claims file. The respondents are the 256 medical/psychological consultants.

Type of Request: Approval of an existing information collection.

Number of Responses: 68,000.

Frequency of Response: 1.

Average Burden Per Response: 12 minutes.

Estimated Annual Burden: 13,600 hours.

13. Request for Withdrawal of Application— 20 CFR 404.460—0960-0015. Form SSA-521 is completed by SSA when an individual wishes to withdraw his or her application for Social Security benefits. The respondents are individuals who wish to withdraw their applications for benefits.

Type of Request: Extension 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.

14. Privacy and Disclosure of Official Records and Information: Availability of Information and Records to the Public—20 CFR 401 and 402—0960-0566. The information collected is needed (a) to identify individuals who request access to their records; (b) designate an individual to receive and review sensitive medical records; (c) correct or amend records; (d) obtain consent from an individual to release his/her records to others; (e) facilitate the release of information under the Freedom of Information Act; and (f) to grant a waiver or reduction of fees for records. The respondents are individuals requesting access to their SSA records, correction of their SSA records and disclosure of SSA records. The reporting burden is shown below:

(a) Number of Respondents: 10,000.

Frequency of Response: On Occasion.

Average Burden Per Response: 11 minutes.

Estimated Annual Burden: 1,833 hours.

(b) Number of Respondents: 3,000.

Frequency of Response: On Occasion.

Average Burden Per Response: 2 hours.

Estimated Annual Burden: 6,000 hours.

(c) Number of Respondents: 100.

Frequency of Response: On Occasion.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 17 hours.

(d) Number of Respondents: 200,000.

Frequency of Response: On Occasion.

Average Burden Per Response: 3 minutes.

Estimated Annual Burden: 10,000 hours.

(e) Number of Respondents: 15,000.

Frequency of Response: On Occasion.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 1,250 hours.

(f) Number of Respondents: 400.

Frequency of Response: On Occasion.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 33 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. Application for Special Benefits for World War II Veterans—20 CFR, Subpart C, 408—0960-0615. Form SSA-2000-F6 is used by SSA to elicit information necessary to determine the entitlement of an individual to a monthly benefit under Title VIII of the Social Security Act. The respondents are persons outside the U.S. applying for benefits for themselves (or for someone else) under Title VIII of the Act.

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

Number of Respondents: 400.

Frequency of Response: 1.

Average Burden Per Response: 20 minutes.

Estimated Annual Burden: 133 hours.

2. Third Party Liability Information Statement—42 CFR 433.136-.139—0960-0323. SSA obtains third party liability information for States under the terms of an agreement with the Centers for Medicare and Medicaid Services, which oversees administration of the Medicaid program. Medicaid State agencies use the information that SSA gathers on Form SSA-8019-U2 to bill third parties liable for medical care, support, or services to insure that Medicaid remains the payer of last resort. The respondents are SSI applicants and beneficiaries.

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

Number of Respondents: 95,000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 7,917 hours.

3. Appointment of Representation—20 CFR, 404.1707, 410.684, and 416.1507—0960-0527. The information collected by SSA on form SSA-1696-U4 is used to verify the applicant's appointment of a representative. It allows SSA to inform the representative of items which affect the applicant's claim. The affected public consists of applicants who notify SSA that they have appointed a person to represent them in their dealings with SSA when claiming a right to benefits.

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

Number of Respondents: 551,520.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 91,920.

4. Request for Workers' Compensation/Public Disability Information—20 CFR, Subpart E, 404.408—0960-0098. SSA uses form SSA-1709 to request and/or verify information about workers' compensation or public disability benefits given to Social Security disability recipients so that the proper adjustment is made to their monthly benefits. The respondents are Federal, State, and local agencies administering workers' compensation or public disability benefits, private workers, insurance carriers and public or private self-insured companies.

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

Number of Respondents: 140,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 35,000 hours.

5. Self-Employment/Corporate Officer Questionnaire—20 CFR 404.435(e) 404.446—0960-0487. Form SSA-4184 is used to develop earnings data and corroborate the claimant's allegations of retirement when the claimant is self-employed or a corporate officer. The information collected is used to determine benefit amounts. The respondents are self-employed individuals and corporate officers.

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

Number of Respondents: 20,000.

Frequency of Response: 1.

Average Burden Per Response: 20 minutes.

Estimated Annual Burden: 6,667 hours.

6. Disability Report, Appeal—20 CFR 404.1512 and 416.912, 20 CFR 404.916(c) and 416.1416(c)—0960-0144. SSA uses form SSA-3441 to secure updated resource and condition information from claimants seeking reconsideration of denied disability benefits. The claimant also has the option of providing the information during a personal interview or through SSA's Internet application. This information assists the State DDS and Administrative Law Judges (ALJ) in preparing for appeals and hearings and in issuing a decision on whether or not an individual is entitled to or continues to be entitled to disability benefits. SSA requests completion of the SSA-3441 when individuals appeal denial of Social Security Disability Income (SSDI) and SSI benefits following a previous denial. The respondents are applicants for reconsideration of initial denial of disability benefits or reconsideration of disability cessation and individuals requesting hearings before an ALJ.

Type of Request: Revision of an OMB-approved information collection. SSA will collect this information using both the traditional paper format and electronic formats through SSA information gathering systems and an online Internet collection as follows:

	Number of respondents	Frequency of response	Average burden per response (in minutes)	Estimated annual burden (in hours)
SSA-3441 (Paper Form)	1,079,338	1	30	539,669
Electronic Disability Collection System (EDCS)	16,790	1	30	8,395
I3441 (Internet Form)	16,690	1	60	16,690
Total respondents and burden hours	1,112,818			564,754

Dated: May 22, 2003.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.