2014-10662. 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].

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 July 8, 2014. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Statement Regarding Date of Birth and Citizenship—20CFR 404.716— 0960-0016. Section 205(a) of the Social Security Act (Act) gives the Commissioner of SSA the authority to make rules and regulations, and to establish procedures for collecting evidence from individuals applying for Social Security benefits. When individuals apply for Social Security benefits and cannot provide preferred methods of proving age or citizenship, SSA uses Form SSA-702 to establish these facts. Specifically, SSA uses the SSA-702 to establish age as a factor of entitlement to Social Security benefits, or U.S. citizenship as a payment factor. Respondents are individuals with knowledge about the date of birth or citizenship of applicants filing for one or more Social Security benefits who need to establish age or citizenship.

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-7157	1,200	1	10	200

2. Disability Report-Appeal—20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 422.140, 404.1713, 416.1513, 404.1740(b)(4), 416.1540(b)(4), and 405 Subpart C—0960-0144. SSA requires disability applicants who wish to appeal an unfavorable disability determination to complete Form SSA-3441-BK, the associated Electronic Disability Collect System (EDCS) interview, or the Internet application, i3441. This allows claimants to disclose any changes to their disability or resources that might influence SSA's unfavorable determination. We may use the information to: (1) Reconsider and review an initial disability determination; (2) review a continuing disability; and (3) evaluate a request for a hearing. This information assists the State Disability Determination Services (DDS) and administrative law judges (ALJ) in preparing for the appeals and hearings, and in issuing a determination or decision on an individual's entitlement (initial or continuing) to disability benefits. In addition, the information we collect on the SSA-3441-BK facilitates SSA's collection of medical information to support the applicant's request for reconsideration; request for benefits cessation appeal; and request for a hearing before an ALJ. Respondents are individuals who appeal denial, reduction, or cessation of Social Security disability income and Supplemental Security Income (SSI) payments; who wish to request a hearing before an ALJ; or their representatives.

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-3441-BK	2,396	1	45	1,797
Electronic Disability Collect System (EDCS)	476,771	1	45	357,578
i3441 (Internet)	1,046,938	1	28	488,571
Totals	1,526,105			847,946

3. Request for Hearing by Administrative Law Judge—20 CFR 404.929, 404.933, 416.1429, 404.1433, 418.1350, and 42 CFR 405.722—0960-0269. When SSA denies applicants' or beneficiaries' requests for new or continuing benefits, the Act entitles those applicants or beneficiaries to request a hearing to appeal the decision. To request a hearing, individuals complete Form HA-501, the associated Modernized Claims System (MCS) or Modernized Supplemental Security Income Claims System (MSSICS) interview, or the Internet application (i501). SSA uses the information to determine if the individual: (1) Filed the request within the prescribed time; (2) is the proper party; and (3) took the steps necessary to obtain the right to a hearing. SSA also uses the information to determine: (1) The individual's reason(s) for disagreeing with SSA's prior determinations in the case; (2) if the individual has additional evidence to submit; (3) if the individual wants an oral hearing or a decision on the record; and (4) whether the individual has (or wants to appoint) a representative. The respondents are Social Security benefit applicants and recipients who want to appeal SSA's denial of their request for new or continued benefits, and Medicare Part B recipients who must pay the Medicare Part B Income-Related Monthly Adjustment Amount.

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)
HA-501; Modernized Claims System (MCS); Modernized Supplemental Security Income Claims System (MSSICS)	25,953	1	10	4,326
I501 (Internet iAppeals)	643,516	1	5	53,626
Totals	669,469			57,952

4. Application for Benefits under a U.S. International Social Security Agreement—20 CFR 404.1925— 0960-0448. Section 233(a) of the Act authorizes the President of the United States to broker international Social Security agreements (Totalization Agreements) between the United States and foreign countries. SSA collects information using Form SSA-2490-BK to determine entitlement to Social Security benefits from the United States, or from a country that enters into a totalization agreement with the United States. The respondents are individuals applying for Old Age, Survivors, and Disability Insurance benefits from the United States or from a Totalization Agreement country.

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-2490-BK (MCS)	14,175	1	30	7,088
SSA-2490-BK (paper)	2,025	1	30	1,013
Totals	16,200			8,101

5. Information Collections Conducted by State Disability Determination Services 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. State DDSs collect the information necessary to administer the Social Security Disability Insurance and SSI programs. They collect medical evidence from consultative examination (CE) sources, credential information from CE source applicants, and medical evidence of record (MER) from claimants' medical sources. The DDSs collect information from claimants regarding medical appointments and pain or other symptoms. The respondents are medical providers, other sources of MER, and disability claimants.

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

CE Collections

There are three CE information collections: (1) Medical evidence about claimants' medical condition(s) that DDS's use to make disability determinations when the claimant's own medical sources cannot or will not provide the required information, and proof of credentials from CE providers; (2) CE appointment letters; and (3) CE claimant reports sent to claimants' doctors.

(1) Medical Evidence and Credentials From CE Providers

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Total estimated annual burden (hours)
CE Paper Submissions	1,400,000	1	30	700,000
CE Electronic Submissions	300,000	1	15	75,000
Totals	1,700,000			775,000

(2) CE Appointment Letters and (3) CE Claimants' Report to Medical Providers

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
(b) CE Appointment Letters	880,000	1	5	73,333
(c) CE Claimants' Report to Medical Providers	450,000	1	5	37,500
Totals	1,330,000			110,833

MER Collections

The DDS's collect MER information from the claimant's medical sources to determine a claimant's physical or mental status prior to making a disability determination.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Total estimated annual burden (hours)
Paper Submissions	3,150,000	1	20	1,050,000
Electronic Submissions	9,450,000	1	12	1,890,000
Totals	12,600,000			2,940,000

Pain or Other Symptoms—Impairment Information From Claimants

The DDSs use information about pain or symptoms to determine how pain or symptoms affect the claimant's ability to do work-related activities prior to making a disability determination.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Total estimated annual burden (hours)
Pain or Other Symptoms	2,100,000	1	20	700,000

The total estimated annual burden for all of the categories described in this information collection is 4,525,833 hours.

6. Request for Reconsideration—20 CFR 404.907-404.921, 416.1407-416.1421, 408.1009, and 418.1325—0960-0622. Individuals use Form SSA-561-U2, the associated MCS interview, or the Internet application (i561) to initiate a request for reconsideration of a denied claim. SSA uses the information to document the request and to determine an individual's eligibility or entitlement to Social Security benefits (Title II), SSI payments (Title XVI), Special Veterans Benefits (Title VIII), Medicare (Title XVIII), and for initial determinations regarding Medicare Part B income-related premium subsidy reductions. The respondents are individuals filing for reconsideration of a denied claim.

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-561 and MCS	550,370	1	8	73,383
I561 (Internet iAppeals)	911,330	1	5	75,944
Totals	1,461,700			149,327

7. Teacher Questionnaire and Request for Administrative Information—20 CFR 416.1103(f)—0960-0646. When determining the effects of a child's impairment for children applying for Title II childhood disability benefits, SSA obtains information about the child's functioning from teachers, parents, and others who observe the child on a daily basis. SSA obtains results of formal testing, teacher reports, therapy progress notes, individualized education programs, and other records of a child's educational aptitude and achievement using Forms SSA-5665-BK and SSA-5666. The respondents are parents, teachers, and other education personnel.

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-5665-BK (electronic)	368,098	1	40	245,399
SSA-5665 (paper form)	2,562	1	40	1,708
SSA-5666 (electronic)	137,590	1	30	68,795
SSA-5666 (paper form)	1,843	1	30	922
Totals	510,093			316,824

II. SSA submitted the information collection below to OMB for clearance. Your comments regarding the information collection 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 June 9, 2014. Individuals can obtain copies of the OMB clearance package by writing to [e-mail].

Request for Social Security Earnings Information—20CFR 404.810 & 401.100—0960-0525. The Act permits wage earners, or their authorized representative, to request Social Security earnings information from SSA using Form SSA-7050-F4. SSA uses the information to verify the requestor's right to access to the information and to produce the earnings statement. The respondents are wage earners and their authorized representatives.

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-7050-F4	66,800	1	11	12,247

Dated: May 6, 2014.

Faye Lipsky,

Reports Clearance Director, Social Security Administration.