E6-9148. 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 Public Law 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, Fax: [phone].

(SSA), Social Security Administration, DCFAM, Attn: Reports Clearance Officer, 1333 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. SSA Survey of Online Services Internet Panel-0960-New. SSA plans to conduct an online panel survey with pre-retirement individuals. The survey will ask a number of questions about participants' experiences with SSA's Internet-based services. The results of the survey will be used to assess awareness of SSA Internet-based services and to identify ways to increase awareness of these services in the pre-retirement population. The respondents are individuals ages 50-67 who are employed and who have agreed to be contacted via e-mail for online surveys.

Type of Request: New information collection.

Number of Respondents: 1,000,

Frequency of Response: 1.

Average Burden per Response: 15 minutes.

Estimated Annual Burden: 250 hours.

2. Authorization for the Social Security Administration to Obtain Account Records From a Financial Institution and Request for Records—20 CFR 416.200, 416.203—0960-0293. The SSA-4641-U2 provides financial institutions with the applicant, recipient, or deemor's authorization to disclose records. Responses to the questions are used, in part, to determine whether the resources requirements are met in the Supplemental Security Income (SSI) program. The respondents are financial institutions used by SSI applicants, recipients and/or deemors.

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

Number of Respondents: 500,000.

Frequency of Response: 1.

Average Burden per Response: 6 minutes.

Estimated Annual Burden: 50,000 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. Application for Special Age 72-or-Over Monthly Payments—20 CFR 404.380-404.384—0960-0096. Form SSA-19-F6 collects the information needed to determine whether a claimant can qualify for Special Age 72 payments. Eligibility requirements will be evaluated based on the data collected on this form. The respondents are individuals who reached age 72 before 1972.

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

Number of Respondents: 10.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 2 hours.

2. Medical or Psychological Review of Childhood Disability Evaluation Form (SSA-538)—20 CFR 416.1040, 416.1043, 416.1045, 416.924(g)—0960-0675. 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 Disability Determination Services employees. A childhood disability evaluation is required in each SSI childhood disability case that is reviewed. The respondents are 256 SSA medical and psychological consultants.

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

Number of Responses: 17,000.

Frequency of Response: 1.

Average Burden Per Response: 12 minutes.

Estimated Annual Burden: 3,400 hours.

3. Claimant's Medication—20 CFR 404.1512, 416.912—0960-0289. The HA-4632, completed by applicants for disability benefits, provides an updated list of medications used by the claimant. This enables the Administrative Law Judge hearing the case to fully inquire into the medical treatment the claimant is receiving and the effect of medications on the claimant's impairments and functional capacity. The respondents are applicants for Old Age, Survivors and Disability Insurance (OASDI) benefits, and/or SSI payments.

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.

4. Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare Low-Income Subsidy)—0960-New. Under the aegis of the Medicare Modernization Act of 2003, Medicare beneficiaries can apply for a subsidy for the Medicare Prescription Drug Plan (Part D) program. In some cases selected for the Medicare Quality Review System (OMB No. 0960-0707), SSA will need to verify the details of applicants' accounts at financial institutions to determine if they are eligible for the subsidy. Form SSA-4640 will give SSA the authority to contact financial institutions about beneficiaries' accounts. It will also be used by financial institutions to verify the information requested by SSA. The respondents are applicants for the Medicare Part D program subsidy and financial institutions where applicants have accounts.

Type of Request: New information collection.

Total Estimated Annual Burden: 834 hours.

	Medicare Part D subsidy applicants	Financial institutions	Totals
Number of respondents	10,000	10,000	20,000.
Frequency of response	1	1	1.
Average burden per response (minutes)	1 minute	4 minutes	5 minutes.
Estimated annual burden (hours)	167 hours	667 hours	834 hours.

Dated: June 6, 2006.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.