03-15884. 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 sent to the individuals listed below:

(OMB), Office of Management and Budget, Attn: Desk Officer for SSA, 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. Social Security Disability Report—20 CFR 404.1512 & 416.912—0960-0579

The Social Security Act requires applicants to furnish medical, work history and other evidence or information to prove they are disabled. The information on the Adult Disability Report, together with other evidence and information, will be used by State Disability Determination Services (DDS) to develop medical evidence, assess the alleged disability, and make a determination on whether or not the applicant is disabled under the Act. DDSs are State agencies that make disability determinations on behalf of SSA.

In addition to the traditional paper application, claimants for disability benefits will have the option to complete the Disability Report through the Internet (i3368) or in an interview format with an SSA representative at an SSA field office using the Electronic Disability Collection System (EDCS). Both the i3368 and EDCS formats collect the same information as that contained on the paper SSA-3368, but include enhancements to guide the claimant or interviewer through the application process. For example, the i3368 provides applicants with self-help screens and propagates certain information. Both the i3368 and EDCS applications will, when needed, collect additional information on a claimant's work history. In the paper-based process, however, additional work history information is collected through another form, the SSA-3369, OMB control number 0960-0578. The respondents are applicants for title II and title XVI disability benefits.

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

Collection format	Number of respondents	Frequency of responses	Average burden per response (hours)	Estimated annual burden (hours)
SSA-3368 (Paper Form)	2,040,667	1	1	2,040,667
Electronic Disability Collection System (EDCS)	10,000	1	1	10,000
I3368 (Internet) (Hour burden varies between 11/2 hours and 3 hours based on information required)	66,000	1	21/2	165,000

Total estimated annual burden: 2,215,667.

2. Supplement to Claim of Person Outside the United States—20 CFR 404.460, 422.505(b), 404.460, 404.463 and 42 CFR 407.27(c)—0960-0051

The information collected on Form SSA-21 is used by SSA to determine continuing entitlement to Social Security benefits and the proper benefit amounts of alien beneficiaries living outside the United States (U.S.). It is also used to determine whether benefits are subject to withholding tax. The respondents are comprised of individuals entitled to Social Security benefits who are, will be, or have been residing outside the U.S.

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

Number of Respondents: 35,000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 2,917.

3. Requests for Self-Employment Information, Employee Information, Employer Information—20 CFR, Subpart A, 422.120—0960-0508

SSA uses Forms SSA-L2765, SSA-L3365 and SSA-L4002 to request correct information when an employer, employee or self-employed person reports an individual's earnings without a Social Security Number (SSN) or with an incorrect name or SSN. The respondents are employers, employees or self-employed individuals who are requested to furnish additional identifying information.

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

Number of Respondents: 3,000,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 500,000 hours.

4. Statement of Claimant or Other Person—20 CFR 404.702 & 416.570—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 Supplementary Supplemental Security Income (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, insure 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).

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

Number of Respondents: 305,500.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 76,375 hours.

5. Uniform Administrative Requirements for Grants and Agreements With Institutions of Higher Education, Hospitals, and Other Non-Profit Organizations—20 CFR Part 435-0960-0616

These rules cover the basic administrative reporting and recordkeeping requirements for applicable recipients of grants and agreements. Because very specific requirements must be met, it is necessary that SSA collect significant information from the applicants and grantees to determine if they meet, or continue to meet, the conditions specified. The respondents are institutions of higher education, hospitals, and other non-profit and commercial organizations. SSA currently has a total of 17 grant recipients that are subject to the requirements of the proposed rule.

Type of Requests: Extension of an OMB-approved information collection. The hourly burden as estimated for each of the reporting (Rpt) and recordkeeping (Reckp) requirements is reflected in the following table:

Section No.	Number of responses	Frequency of response	Average burden (hours)	Estimated annual (hours)
435.21 Rec-	1	N/A	40	40
435.23 Rec-	94	Quarterly (4)	1	376
435.25 Rpt	14	Biannually	4	112
435.33 Rpt	1	Annually (1)	1	1
435.44 Rpt	1	Annually (1)	2	2
435.51 Rpt	150	Quarterly (4)	12	7,200
435.53 Rec-	150	Annually (1)	8	1,200
435.81 Rpt	1	Annually (1)	16	16
435.82 Rpt	1	Annually (1)	8	8

Total estimated annual burden: 8,955 hours.

6. State Mental Institution Policy Review—20 CFR, Subpart U, 404.2001-2065, Subpart F, 416.601-416.665-0960-0110

The Social Security Act provides that the Commissioner of Social Security shall establish a system of accountability monitoring for institutions in each state that serve as a representative payee for recipients of Social Security and SSI benefits. As part of this accountability process, SSA collects information on Form SSA-9584 to determine whether the institution policies and practices conform to SSA's regulations on the use of benefits and whether the institution is performing other duties and responsibilities required of a representative payee. The information also provides a basis for conducting an onsite review of the institution and is used in the preparation of the subsequent report of findings. The respondents are state mental institutions that serve as representative payees.

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

Number of Respondents: 125.

Frequency of Response: 1.

Average Burden Per Response: 60 minutes.

Estimated Annual Burden: 125 hours.

7. Application for Search of Census Records for Proof of Age—20 CFR 404.716-0960-0097

The information collected on Form SSA-1535-U3 is required to provide the Census Bureau with sufficient identification information, which will allow an accurate search of census records to establish proof of age for an individual applying for Social Security Benefits. It is used for individuals who must establish age as a factor for entitlement. The respondents are individuals applying for Social Security benefits who need to document their date of birth.

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

Number of Respondents: 18,000.

Number of Response: 1.

Average Burden per Response: 12 minutes.

Estimated Average Burden: 3,600.

8. Function Report—Adult—20 CFR 404.1512 and 416.912—0960-NEW

Form SSA-3373 records information about the disability applicant's impairment-related limitations and ability to function. It documents the types of information specified in SSA regulations and provides disability inteviewers with a convenient means to record information about how the claimant's condition affects his or her ability to function. This information, together with medical evidence, forms the evidentiary basis upon which the initial disaiblity proces is founded. The respondents are title II and XVI benefits applicants.

Type of Request: New information collection.

Number of Respondents: 4,005,367.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 2,002,684.

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. 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 recipeints. 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 organizatioanal representative payees designated to receive funds on behalf of Social Security beneficiaries and/or SSI recipients.

Type of Request: Extensioin 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.

2. Employee Work Activity Questionnair—20 CFR, Subpart P, 404.1574 and 404.1592—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 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.

3. Disability Hearing Officer's Decision Title XVI Disabled Child Continuing Disability Review—20 CFR 404 Subpart J and 20 CFR 416 Subpart I&N—OMB No. 0960-0657

Both federal and state disability hearing officers (DHOs) use the SSA-1209 in preparing the disability determination. The form provides the framework for addressing the crucial elements of the case in a sequential and logical fashion. The completed form will be the official document of the decision. A copy becomes the personalized portion of the notice to the claimant/representative. the respondents are both federal and state disability hearing officers.

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

Number of Respondents: 35,000.

Frequency of Response: 1.

Average Burden Per Response: 1 hour 25 minutes.

Estimated Annual Burden: 49,583 hours.

4. Claimant's Statement About Loan of Food and Shelter (SSA-5062), and Statement About Food or Shelter Provided to Another (SSA-L5063)—20 CFR 416.1130 through 416.1148—0950-0529

Forms SSA-5062 and SSA-L5063 are used to obtain statements about food and/or shelter provided to an SSI claimant. SSA uses the information to determine whether food and/or shelter are a bona fide loan or should be counted as income. This determination can affect eligibility for SSI and the amount of SSI that is payable. The respondents are claimants for SSI benefits and individuals, who provide (loan) food or shelter to SSI claimants.

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

	SSA 5062	SSA L5063
Number of respondents	65,540	65,540
Frequency of Response	1	1
Average Burden of Response	10	10
Estimated Annual Burden	10,923	10,923

Dated: June 8, 2003.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.