2019-14173. Agency Information Collection Activities: Proposed 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 extensions and 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]

Or you may submit your comments online through www.regulations.gov,, referencing Docket ID Number [SSA-2019-0026].

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 September 3, 2019. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Application for Child's Insurance Benefits—20 CFR 404.350-404.368, 404.603, & 416.350—0960-0010. Title II of the Social Security Act (Act) provides for the payment of monthly benefits to children of an insured retired, disabled, or deceased worker. Section 202(d) of the Act discloses the conditions and requirements the applicant must meet when filing an application. SSA uses the information on Form SSA-4-BK to determine entitlement for children of living and deceased workers to monthly Social Security payments. Respondents are guardians completing the form on behalf of the children of living or deceased workers, or the children of living or deceased workers.

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)
Application for Child's Insurance Benefits/Death Claim/Paper SSA-4-BK	1,204	1	12	241
Application for Child's Insurance Benefits/Death Claim/Modernized Claims System (MCS) and Preliminary Claims System (PCS)	204,777	1	11	37,542
Application for Child's Insurance Benefits/Life Claim/Paper SSA-4-BK	3,484	1	12	697
Application for Child's Insurance Benefits/Life Claim/MCS and PCS	422,267	1	11	77,416
Totals	631,732			115,896

2. 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', claimants', or beneficiaries' requests for new or continuing disability benefits or payments, the Act entitles those applicants, claimants, 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 Supplemental Security Income (SSI) Claims System 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 disability applicants and recipients who want to appeal SSA's denial of their request for new or continued benefits for disability and non-medical hearing requests; 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; MCS; SSI Claims System	10,325	1	10	1,721
i501 (Internet iAppeals)	653,318	1	5	54,443
Totals	663,643			56,164

3. Travel Expense Reimbursement—20 CFR 404.999(d) and 416.1499—0960-0434. The Act provides for travel expense reimbursement from Federal and State agencies for claimant travel incidental to medical examinations, and to parties, their representatives, and all reasonably necessary witnesses for travel exceeding 75 miles to attend medical examinations; reconsideration interviews; and proceedings before an administrative law judge. Reimbursement procedures require the claimant to provide: (1) A list of expenses incurred, and (2) receipts of such expenses. Federal and state personnel review the listings and receipts to verify the reimbursable amount to the requestor. The respondents are claimants for Title II benefits and Title XVI payments, their representatives, and witnesses.

Type of Request: Extension 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)
404.99(d) & 416.1499	60,000	1	10	10,000

4. Certificate of Coverage Request—20 CFR 404.1913—0960-0554. The United States (U.S.) has agreements with 30 foreign countries to eliminate double Social Security coverage and taxation where, except for the provisions of the agreement, a worker would be subject to coverage and taxes in both countries. These agreements contain rules for determining the country under whose laws the worker's period of employment is covered, and to which country the worker will pay taxes. The agreements further dictate that, upon the request of the worker or employer, the country under whose system the period of work is covered will issue a certificate of coverage. The certificate serves as proof of exemption from coverage and taxation under the system of the other country. The information we collect assists us in determining a worker's coverage and in issuing a U.S. certificate of coverage as appropriate. Per our agreements, we ask a set number of questions to the workers and employers prior to issuing a certificate of coverage; however, our agreements with Denmark, Netherlands, Norway, and Sweden require us to ask more questions in those countries. Respondents are workers and employers wishing to establish exemption from foreign Social Security taxes.

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)
Requests via Letter—Individuals (minus Denmark, Netherlands, Norway, Poland & Sweden)	5,833	1	40	3,889
Requests via Internet—Individuals (minus Denmark, Netherlands, Norway, Poland & Sweden)	9,761	1	40	6,507
Requests via Letter—Individuals in Denmark, Netherlands, Norway, & Sweden	284	1	44	208
Requests via Letter—Individuals in Poland	16	1	41	11
Requests via Internet—Individuals in Denmark, Netherlands, Norway, & Sweden	427	1	44	313
Requests via Internet—Individuals in Poland	25	1	41	17
Requests via Letter—Employers (minus Denmark, Netherlands, Norway, Poland & Sweden)	26,047	1	40	17,365
Requests via Internet—Employers (minus Denmark, Netherlands, Norway, Poland, & Sweden)	39,096	1	40	26,064
Requests via Letter—Employers in Denmark, Netherlands, Norway, & Sweden	1,137	1	44	834
Requests via Letter—Employers in Poland	57	1	41	39
Requests via Internet—Employers in Denmark, Netherlands, Norway, & Sweden	1,704	1	44	1,250
Requests via Internet—Employers in Poland	86	1	41	59
Totals	84,473			56,556

5. Privacy and Disclosure of Official Records and Information; Availability of Information and Records to the Public—20 CFR 401.40(b)&(c), 401.55(b), 401.100(a), 402.130, 402.185—0960-0566. SSA established methods for the public to: (1) Access their SSA records; (2) allow SSA to disclose records; (3) correct or amend their SSA records; (4) consent for release of their records; (5) request records under the Freedom of Information Act (FOIA); and (6) request access to an extract of their SSN record. SSA often collects the necessary information for these requests through a written letter, with the exception of the consent for release of records, for which we use Form SSA-3288. The respondents are individuals requesting access to, correction of, or disclosure of SSA records.

Type of Request: Extension 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)
Access to Records	10,000	1	11	1,833
Designating a Representative for Disclosure of Records	3,000	1	120	6,000
Amendment of Records	100	1	10	17
Consent of Release of Records	3,000,760	1	3	150,038
FOIA Requests for Records	15,000	1	5	1,250
Respondents who request access to an extract of their SSN record	10	1	8.5	1
Totals	3,028,870			159,139

6. Disability Report—Child—20 CFR 416.912—0960-0577—Sections 223(d)(5)(A) and 1631(e)(1) of the Act require SSI claimants to furnish medical and other evidence to prove they are disabled. SSA uses Form SSA-3820 to collect various types of information about a child's condition from treating sources or other medical sources of evidence. The State Disability Determination Services evaluators use the information from Form SSA-3820 to develop medical and school evidence, and to assess the alleged disability. The information, together with medical evidence, forms the evidentiary basis upon which SSA makes its initial disability evaluation. The respondents are claimants seeking SSI childhood disability payments.

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-3820	177,572	1	90	266,358
EDCS	1,000	1	120	2,000
i3820	176,572	1	120	353,144
Totals	355,144			621,502

7. Request for Reconsideration—20 CFR 404.907-404.921, 416.1407-416.1421, 408.1009, and 418.1325—0960-0622. The Act states those individuals who are dissatisfied with the results of an initial determination regarding their Title II disability; Tile XVI disability (SSI); Title VIII (Special Veterans benefits); or Title XVIII (Medicare benefits), can request a reconsideration hearing. Individuals use Form SSA-561-U2; the associated MCS or SSI Claims System 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 applicants, claimants, beneficiaries, or recipients filing for reconsideration of an initial determination.

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 Modernized Claims System (MCS)	330,370	1	8	40,049
I561 (Internet iAppeals)	1,161,300	1	5	96,775
Totals	1,491,670			136,824

8. Request to Withdraw a Hearing Request; Request to Withdraw an Appeals Council Request for Review; and Administrative Review Process for Adjudicating Initial Disability Claims—20 CFR parts 404, 405, and 416—0960-0710. Claimants have a statutory right under the Act and current regulations to apply for Social Security Disability Insurance (SSDI) benefits or SSI payments. SSA collects information at each step of the administrative process to adjudicate claims fairly and efficiently. SSA collects this information to establish a claimant's right to administrative review, and determine the severity of the claimant's alleged impairments. SSA uses the information we collect to determine entitlement or continuing eligibility to SSDI benefits or SSI payments, and to enable appeals of these determinations. In addition, SSA collects information on Forms HA-85 and HA-86 to allow claimants to withdraw a hearing request or an Appeals Council review request. The respondents are applicants for Title II SSDI or Title XVI SSI benefits; their appointed representatives; legal advocates; medical sources; and schools.

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

20 CFR section No.	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
404.961, 416.1461, 405.330, and 405.366	12,220	1	20	4,073
404.950, 416.1450, and 405.332	1,040	1	20	347
404.949 and 416.1449	2,868	1	60	2,868
405.334	20	1	60	20
404.957, 416.1457, and 405.380	21,041	1	10	3,507
405.381	37	1	30	19
405.401	5,310	1	10	885
404.971 and 416.1471 (HA-85; HA-86)	1,606	1	10	268
404.982 and 416.1482	1,687	1	30	844
404.987 & 404.988 and 416.1487 & 416.1488 and 405.601	12,425	1	30	6,213
404.1740(b)(1)	150	1	2	5
416.1540(b)(1)	150	1	2	5
404.1512, 404.1740(c)(4), 416.912, and 416.1540(c)(4)	150	1	2	5
405.372(c)	5,310	1	10	885
405.1(b)(5)	833	1	30	417
405.372(b)
405.505	833	1	30	417
405.1(c)(2)	5,310	1	10	885
405.20	5,310	1	10	885
Totals	76,300			22,548

9. Request for Accommodation in Communication Method—0960-0777. SSA allows disabled or impaired Social Security applicants, beneficiaries, recipients, and representative payees to choose one of seven alternative methods of communication they want SSA to use when we send them benefit notices and other related communications. The seven alternative methods we offer are: (1) Standard print notice by first-class mail; (2) standard print mail with a follow-up telephone call; (3) certified mail; (4) Braille; (5) Microsoft Word file on data CD; (6) large print (18-point font); or (7) audio CD. However, respondents who want to receive notices from SSA through a communication method other than the seven methods listed above must explain their request to us. Those respondents use Form SSA-9000 to: (1) Describe the type of accommodation they want; (2) disclose their condition necessitating the need for a different type of accommodation; and (3) explain why none of the seven methods described above are sufficient for their needs. SSA uses Form SSA-9000 to determine, based on applicable law and regulation, whether to grant the respondents' requests for an accommodation based on their impairment or disability. SSA collects this information electronically through either an in-person interview or a telephone interview during which the SSA employee keys in the information on our iAccommodate Intranet screens. The respondents are disabled or impaired Social Security applicants, beneficiaries, recipients, and representative payees who ask SSA to send notices and other communications in an alternative method besides the seven modalities we currently offer.

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-9000/iAccommodate	5,000	1	20	1,667

10. Report of Adult Functioning-Employer—20 CFR 404.1512 and 416.912—0960-0805. Section 205(a), 223(d)(5)(A), 1631(d)(1), and 1631(e)(1) of the Act require claimants' applying for SSDI benefits or SSI payments to provide SSA with medical and other evidence of their disability. 20 CFR 404.1512 and 20 CFR 416.912 of the Code of Federal Regulations provides detailed requirements of the types of evidence SSDI beneficiaries and SSI claimants must provide showing how their impairment(s) affect their ability to work (e.g., evidence of age; education and training, work experience; daily activities; efforts to work; and any other evidence). Past employers familiar with the claimant's ability to perform work activities complete Form SSA-385-BK, Report of Adult Functioning-Employer to provide SSA with information about the employees day-to-day functioning in the work setting. SSA and Disability Determination Services use the information Form SSA-3385-BK collects as the basis to determine eligibility or continued eligibility for disability benefits. The respondents are claimants' past employers.

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

Modality of completion	Number of responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-3385-BK	3,601	1	20	1,200

Dated: June 27, 2019.

Naomi Sipple,

Reports Clearance Officer, Social Security Administration.