2024-20713. Agency Information Collection Activities: Proposed Request

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)	Average theoretical hourly cost amount (dollars) *	Average wait time in field office or for teleservice centers (minutes) **	Total annual opportunity cost (dollars) ***
SSA-821-BK In Office	64,330	1	30	32,165	* $13.30	** 24	*** 770,030
SSA-821-BK Phone	128,660	1	30	64,330	* 13.30	** 19	*** 1,397,458
SSA-821-BK Returned Via Mail	192,990	1	40	128,660	* 13.30		*** 1,710,380
SSA-821-BK Electronic	25,320	1	45	18,990	* 13.30		*** 252,567
Totals	411,300			244,145			*** 4,130,435
* We based this figure on the average of both DI payments based on SSA's current FY 2024 data ( https://mwww.ba.ssa.gov/​legislation/​2024FactSheet.pdf), and U.S. worker's hourly wages, as reported by Bureau of Labor Statistics data ( https://www.bls.gov/​oes/​current/​oes_​nat.htm).
** We based this figure on averaging the average FY 2024 wait times for field offices, based on SSA's current management information data.
*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

2. Claimant's Medication—20 CFR 404.1512, 416.912—0960-0289. To receive Old Age Survivors and Disability Insurance (OASDI) and SSI payments, the relevant State Disability Determination Service (DDS) or field office (FO) must first adjudicate claimants' applications. If the DDS or FO denies an initial application, the claimants may request for reconsideration of the initial denial. At that time, the claimants may submit addition documentation to further justify their claims. If the DDS denies the claim at the reconsideration level, the claimant may then request a hearing before a judge. Before the hearing, SSA allows the claimant to submit additional evidence to support their claim. In addition, since judges must obtain information from the claimant to update and complete their medical record and to verify the accuracy of the information, SSA also sends the claimant Form HA-4632, Claimant's Medications, to request information from the claimant regarding the current medications they use. This information helps the judge overseeing the case to fully investigate: (1) the claimant's ( print page 74352) medical treatment and (2) the effects of the medications on the claimant's medical impairments and functional capacity. The judge makes the completed form a part of the documentary evidence of record, placing it in the official record of the proceedings as an exhibit. The respondents are applicants (or their representatives) for OASDI or SSI payments who request a hearing to contest an agency denial of their 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)	Average theoretical hourly cost amount (dollars) *	Average wait time in field office (minutes) **	Total annual opportunity cost (dollars) ***
HA-4632—PDF/paper version	51,000	1	20	17,000	* $13.30	** 21	*** $463,505
Electronic Records Express Submissions	249,000	1	20	83,000	* 31.48		*** 2,612,840
Totals	300,000			100,000			*** 3,076,345
* We based this figure on the average DI payments based on SSA's current data ( https://www.ssa.gov/​legislation/​2024FactSheet.pdf) and on the average U.S. worker's hourly wages, as reported by Bureau of Labor Statistics data ( https://www.bls.gov/​oes/​current/​oes_​nat.htm).
** We based this figure on averaging both the average FY 2024 wait times for field offices and teleservice centers, based on SSA's current management information data.
*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

3. Questionnaire for Children Claiming SSI Benefits—20 CFR 416.912(a)—0960-0499. Sections 1614 and 1631 of the Act allows SSA to determine the eligibility of an applicant's claim for SSI payments. Parents or legal guardians seeking to obtain or retain SSI eligibility for their children use Form SSA-3881-BK to provide SSA with the addresses of non-medical sources such as schools, counselors, agencies, organizations, or therapists who would have information about a child's functioning. SSA uses this information to help determine a child's claim or continuing eligibility for SSI. The respondents are the parents, guardians, or other caretakers of: (1) applicants who appeal SSI childhood disability decisions; or (2) recipients undergoing a continuing disability review.

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)	Average theoretical hourly cost amount (dollars) *	Average wait time in field office (minutes) **	Total annual opportunity cost (dollars) ***
SSA-3881-BK (Paper Version)	98,307	1	30	49,154	* $31.48	** 24	*** $2,785,256
SSA-3881-BK (Intranet Version)	52,936	1	30	26,468	* 31.48	** 21	*** 1,416,474
Totals	151,243			75,622			*** 4,201,730
* We based this figure on average U.S. worker's hourly wages, as reported by Bureau of Labor Statistics data ( https://www.bls.gov/​oes/​current/​oes_​nat.htm).
** We based this figure on the average FY 2024 wait times for field offices and hearings office, as well as by averaging both the average FY 2024 wait times for field offices (24 minutes) and teleservice centers (19 minutes), based on SSA's current management information data.
*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

4. Requests for Self-Employment Information, Employee Information, and Employer Information—20 CFR 422.120—0960-0508. When SSA cannot identify Form W-2 wage data for an individual, we place the data in an earnings suspense file and contact the individual (and certain instances the employer) to obtain the correct information. If the respondent furnishes the name and Social Security Number (SSN) information that agrees with SSA's records, or provides information that resolves the discrepancy, SSA adds the reported earnings to the respondent's Social Security record. We use Forms SSA-L2765, SSA-L3365, and SSA-L4002 for this purpose. The respondents are self-employed individuals and employees whose name and SSN information do not agree with their employer's and SSA's records.

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)	Average theoretical hourly cost amount (dollars) **		Total annual opportunity cost (dollars) ***
SSA-L2765 *	1	1	10	1	** $31.48		*** $31.48
SSA-L3365 *	1	1	10	1	** 31.48		*** 31.48
SSA-L4002 *	1	1	10	1	** 31.48		*** 31.48
( print page 74353)
Totals	1			3			*** 94
* SSA does not currently send out any of these collections; however, we included 1 hour burden placeholders for each collection, in the event we need to send these notices out in the near future.
** We based this figure on average U.S. worker's hourly wages, as reported by Bureau of Labor Statistics data ( https://www.bls.gov/​oes/​current/​oes_​nat.htm).
*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

5. Function Report—Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday)—20 CFR 416.912 and 416.924a(a)(2)—0960-0542. As part of SSA's disability determination process, we use Forms SSA-3375-BK through SSA-3379-BK to request information from a child's parent or guardian for children applying for SSI. The five different versions of the form contain questions about the child's day-to-day functioning appropriate to a particular age group; thus, respondents use only one version of the form for each child. The adjudicative team (disability examiners and medical or psychological consultants) of State disability determination services offices collect the information on the appropriate version of this form (in conjunction with medical and other evidence) to form a complete picture of the children's ability to function and their impairment-related limitations. The adjudicative team uses the completed profile to determine: (1) if each child's impairment(s) results in marked and severe functional limitations; and (2) whether each child is disabled. The respondents are parents and guardians of child applicants for SSI.

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

Modality of completion (paper & Intranet versions)	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)	Average theoretical hourly cost amount (dollars) *	Average wait time in field office or teleservice center (minutes) **	Total annual opportunity cost (dollars) ***
SSA-3375	26,864	1	20	8,955	* $31.48	** 21	*** $577,878
SSA-3376	53,347	1	20	17,782	* 31.48	** 21	*** 1,147,540
SSA-3377	108,745	1	20	36,248	* 31.48	** 21	*** 2,339,247
SSA-3378	193,800	1	20	64,600	* 31.48	** 21	*** 4,168,896
SSA-3379	142,006	1	20	47,335	* 31.48	** 21	*** 3,054,725
Totals	524,762			174,921			*** 11,288,286
* We based this figure on the average U.S. worker's hourly wages, as reported by Bureau of Labor Statistics data ( https://www.bls.gov/​oes/​current/​oes_​nat.htm).
** We based this figure on the average FY 2024 wait times for field offices (24 minutes) and Teleservice Centers (19 minutes), based on SSA's current management information data.
*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

6. Representative Payee Report of Benefits and Dedicated Account—20 CFR 416.546, 416.635, 416.640, and 416.665—0960-0576. SSA requires representative payees (RPs) to manage the dedicated account in accordance with our rules, including using the funds for permitted expenditures and reporting on the use of funds. When the SSI recipient requires a dedicated account, SSA notifies the RP to inform them of the need to open the dedicated account and of the rules for managing a dedicated account, including the required submission of a written report accounting for the use of money paid to Social Security or Supplemental Security Income (SSI) recipients into the dedicated account. SSA allows the respondent to submit their own written report, or use Form SSA-6233, which simplifies the process for the respondents. SSA uses Form SSA-6233 to: (1) ensure the RPs use the payments for the recipient's current maintenance and personal needs and properly conserves the remainder; and (2) confirm the funds paid into the dedicated account are spent and saved in compliance with the law. Respondents are RPs for SSI and Social Security recipients.

Type of Request: Revision of an OMB-approved information collection. ( print page 74354)

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)	Average theoretical hourly cost amount (dollars) *	Average wait time in field office or for teleservice centers (minutes) **	Total annual opportunity cost (dollars) ***
SSA-6233	68,000	1	20	22,667	* $31.48	** 21	*** $1,462,781
* We based this figure on average U.S. worker's hourly wages, as reported by Bureau of Labor Statistics data ( https://www.bls.gov/​oes/​current/​oes_​nat.htm#00-0000).
** We based this figure on averaging both the average FY 2024 wait times for field offices (24 minutes) and teleservice centers (19 minutes), based on SSA's current management information data.
*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

7. Sheltered Workshop Wage Reporting—0960-0771. Sheltered workshops are private non-profit organizations or institutions that implement a recognized program of rehabilitation for handicapped workers or provide such workers with remunerative employment or other occupational rehabilitating activity of an educational or therapeutic nature. Sheltered workshops perform a service for their clients by reporting monthly wages directly to SSA. SSA uses the information these workshops provide to verify and post monthly wages to SSI recipient's records. Most workshops report monthly wage totals to their local SSA office, so we can adjust the client's SSI payment amount in a timely manner and prevent overpayments. Sheltered workshops are motivated to report wages voluntarily as a service to their clients. Respondents are sheltered workshops that report monthly wages for services performed in the workshop.

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

Modality of completion	Number of respondents	Frequency of response	Total number of responses	Average burden per response (minutes)	Estimated total annual burden (hours)	Average theoretical hourly cost amount (dollars) *	Average wait time in field office (minutes) **	Total annual opportunity cost (dollars) ***
Sheltered Workshop Wage Reporting	244	12	2,928	15	732	* $23.28	** 24	*** $19,322
* We based this on average Rehabilitation Counselors hourly salary, as reported in Bureau of Labor Statistics data ( https://www.bls.gov/​oes/​current/​oes211015.htm)
** We based this figure on the average FY 2024 wait times for field offices, based on SSA's current management information data.
*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.