01-20030. 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. 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 at the following addresses:

(OMB)

Office of Management and Budget, Attn: Desk Officer for SSA, New Executive Office Building, Room 10230, 725 17th St., NW, Washington, D.C. 20503

(SSA)

Social Security Administration, DCFAM, Attn: Frederick W. Brickenkamp, 1-A-21 Operations Bldg., 6401 Security Blvd., Baltimore, MD 21235

I. The information collections listed below 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 410-965-4145, or by writing to him at the address listed above.

1. Reporting Events, SSI-0960-0128. Supplemental Security Income (SSI) applicants, recipients and their representative payees use Form SSA-8150-EV (or the Spanish version) to report by mail changes in circumstances that could affect eligibility for SSI. The Social Security Administration uses the reported changes on the form to determine eligibility and correct payment amounts for SSI payments, which may include federally, administered State supplementary payments. The respondents are SSI applicants, recipients, and their representative payees.

Number of Respondents: 33,200.

Frequency of Response: 1.

Average Burden Per Response: 5.

Estimated Annual Burden: 2,767 hours.

2. Disability Determination And Transmittal—0960-0437. The information collected on Form SSA-831-U3/C3 is used by SSA to document the State agency determination as to whether an individual who applies for disability benefits is eligible for those benefits based on his/her alleged disability. SSA also uses the form for program management and evaluation. The respondents are State Disability Determination Services (DDS) adjudicating Title II and Title XVI Disability claims.

Number of Respondents: 2,860,859.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 715,215 hours.

3. Cessation or Continuance of Disability or Blindness Determination—0960-0443. The information on Form SSA-832-U3/C3 is used by SSA to document determinations as to whether an individual's disability benefits should be terminated or continued on the basis of his/her impairment. The respondents are State DDS employees adjudicating Title XVI Disability claims.

Number of Respondents: 600,758.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 300,379 hours.

4. Cessation Or Continuance Of Disability Or Blindness Determination And Transmittal—0960-0442. The information on Form SSA-833-U3/C3 is used by SSA to make determinations of whether individuals receiving title II disability benefits should continue to be unable to engage in substantial gainful activity and are still eligible to receive benefits. The respondents are State DDS employees.

Number of Respondents: 466,124.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 233,062 hours.

5. Modified Benefit Formula Questionnaire—0960-0395. The information collected on Form SSA-150 is needed by SSA to determine the correct formula to use in computing Social Security benefits for someone who also receives benefits from employment not covered by Social Security. The respondents consist of claimants for Social Security benefits who are also entitled to benefits not covered by Social Security.

Number of Respondents: 90,000.

Frequency of Response: 1.

Average Burden Per Response: 8 minutes.

Estimated Average Burden: 12,000 hours.

6. Internet Disability Report—0960-NEW. The Social Security Act requires applicants to furnish medical and other evidence and information to prove they are disabled. Applicants for disability benefits will be given the option to provide information needed to help determine they are disabled through the Internet. The Internet Disability Report, which is similar to the form SSA-3368-BK, Disability Report-Adult, will collect allegations of disability and gather information about the disabling condition and sources of medical evidence. Collecting this information is critical to case development and adjudication. The information on the Disability Report, together with other evidence and information, will be used by State DDSs (who make disability decisions on behalf of SSA) to develop medical evidence, assess the alleged disability, and make a determination on whether or not the applicant is disabled under the Act. The respondents are applicants for title II and title XVI disability benefits.

Number of Respondents: 66,000.

Frequency of Response: 1.

Average Burden Per Response: 2 hours.

Estimated annual Burden: 132,000 hours.

6. National Study of Health and Activity (NSHA)—0960-0609. The Social Security Administration is sponsoring the NSHA to serve as the cornerstone of SSA's future disability policy development and research agenda. NSHA is a national disability study that consists of gathering information from interviews, medical examinations and medical records to be used to make simulated Disability Determination Service disability decisions. A pilot study was conducted in 2000 and revisions were made to the study instruments and procedures based on the analysis of the pilot data. To test the usability of the revisions, a pretest of the survey instruments and procedures is necessary prior to beginning the main study. This pretest will be conducted on volunteers obtained from SSA disability rolls and nondisabled individuals recruited from the community. Pretesting activities will encompass all components of the study including screening, interviewing, medical examinations, collection of medical records, and assembling a folder of all data for the study's simulated disability decision process. Once the results from this pretest are available, the NSHA instruments and procedures will be further refined for the dress rehearsal and main study.

Referencing the following table, SSA will screen up to 400 individuals to obtain 140 volunteers to participate in activities (2) through (5). SSA will contact approximately 420 health care providers to obtain the medical records of the volunteers (item (6). The public reporting burden is as follows:

Information collection activity	Number of respondents	Frequency of response	Average hours per response	Estimated annual burden
(1) Recruitment screening	400	1	.17	68
(2) Household screener	140	1	.33	46
(3) Sample person interview	140	1	1.5	210
(4) Respondent medical exam information	140	1	2	280
(5) Comments on pretest materials	140	1	.25	35
(6) Collecting medical evidence of record from healthcare provider	420	1	.5	210
Total				849

7. The Internet Social Security Benefits Application (ISBA)—0960-0618. One of the requirements for obtaining Social Security benefits is the filing of an application so that a determination may be made on the applicant's eligibility for monthly benefits. ISBA, which is available at the Social Security Administration's (SSA) Internet site, is one method that an individual can choose to file an application for benefits. In order to make a determination on eligibility for benefits, it is necessary to elicit from the applicant information about the date and place of birth, current and recent work, receipt of non-covered pensions etc. Currently, the ISBA can only be used to apply for retirement and spouse's benefits. SSA plans to expand ISBA to encompass Disability Insurance Benefits (DIB). SSA has used information collected by ISBA to entitle individuals to retirement insurance benefits and/or spouse's benefits. The information collected by the expanded ISBA will be used to entitle individuals to DIB as well. The respondents are applicants for retirement insurance benefits, spouse's benefits and disability benefits. Below is an estimate of the public reporting burden:

Type of benefit	Number of respondents	Frequency of response	Average burden per response (in minutes)	Estimated annual burden (in house)
RIB	130,000	1	20	43,333
DIB	39,000	1	25-30	16,542
Total	169,000			59,875

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 on [phone], or by writing to him at the address listed above.

1. Contact with the Representative Payee and Contact with Beneficiary—0960-NEW. SSA will use the SSA-L4945, Contact with the Representative Payee, and SSA-L4947, Contact with Beneficiary, to inform respondents and conduct quality reviews of payments made under the titles II and XVI (Old-Age, Survivors and Disability Insurance/SSI) programs. Cases for the review will be selected randomly and the information solicited will be used for verification of payment data on record in the claims folder and SSA's Master Beneficiary Record. Form SSA-L4945 will be used to notify Representative Payees who have the responsibility of managing payments for an SSA Beneficiary that the case has been selected for the review process and to request the required information. Form SSA-L4947 will be used to notify beneficiaries that their case has been selected for the review process and request the needed information. Both letters contain information that must be verified and returned to SSA under the review process. The respondents are beneficiaries and representative payees for beneficiaries receiving title II and title XVI benefits.

Number of Respondents: 200.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 50 hours.

2. RSI/DI Quality Review Case Analysis-Sampled Number Holder, Auxiliaries/Survivors-Parent, Stewardship AET Workbook—0960-0189. SSA uses the information collected on forms SSA-2930, 2931 and 2932 to establish a national payment accuracy rate for all cases in payment status; measure the accuracy rate for newly adjudicated claims for beneficiaries receiving old-age, survivors, or disability insurance; and to serve as a source of information regarding problem areas in the RSI/DI programs. Form SSA-4659 is used to evaluate and determine the effectiveness of the annual earnings test and to use the results in developing ongoing improvements in the process. The respondents are beneficiaries and representative payees for beneficiaries receiving old age, survivors, or disability insurance.

	Respondents	Frequency of response	Average burden per response	Estimated annual burden
SSA-2930	3,000	1	30	1,500
SSA-2931	1,500	1	30	750
SSA-2932	650	1	20	217
SSA-4659	325	1	10	54
Total burden				2,521

3. Request for Change in Time/Place of Disability Hearing-0960-0348. The information on Form SSA-769 is used by SSA and the State DDSs to provide claimants with a structured format to exercise their right to request a change in the time or place of a scheduled disability hearing. The information is used as a basis for granting or denying requests for changes and for rescheduling hearings. The respondents are claimants who wish to request a change in the time or place of their disability hearing.

Number of Respondents: 7,483.

Frequency of Response: 1.

Average Burden Per Response: 8 minutes.

Estimated Annual Burden: 998 hours.

4. Request for Reconsideration—Disability Cessation—0960-0349. The information collected on form SSA-789 is used by SSA to schedule hearings, and to develop additional evidence for claimants who have received an initial or revised determination that a disability did not exist or has ceased. The collected information also indicates whether an interpreter is needed. The respondents are disability beneficiaries who file a claim for reconsideration.

Number of Respondents: 49,000.

Frequency of Response: 1.

Average Burden Per Response: 12 minutes.

Estimated Annual Burden: 9,800 hours.

5. Agency/Employer Government Pension Offset Questionnaire—0960-0470. The Information collected on Form SSA-L4163 will provide SSA with accurate information from the agency paying the pension, for purposes of applying the pension-offset provision. The form will only be used when (1) the claimant does not have the information and (2) the pension-paying agency has not cooperated with the claimant. The respondents are Federal, State, or local government agencies that have information needed by SSA to determine whether the Government Pension Offset provisions apply and the amount of offset.

Number of Respondents: 1,000.

Frequency of Response: 1.

Average Burden Per Response: 3 minutes.

Estimated Annual Burden: 50 hours.

6. Child-Care Dropout Questionnaire—0960-0474. The information collected on Form SSA-4162 is used by SSA to determine whether an individual qualifies for a child care exclusion in computing the individual's disability benefit amount. The respondents are applicants for disability benefits.

Number of Respondents: 2,000.

Frequency of Response: 1.

Average Burden Per Response: 5 minutes.

Estimated Annual Burden: 167 hours.

7. Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution—0960-0293. Form SSA-4641-U2 provides financial institutions with the customer's authorization to disclose records, as required by Public Law 95-630. Responses to the questions are used, in part, to determine whether resource requirements are met in the SSI program. The respondents are financial institutions (banks, savings and loans, credit unions, etc.).

Number of Respondents: 500,000.

Frequency of Response: 1.

Average Burden Per Response: 6 minutes.

Estimated Annual Burden: 50,000 hours.

8. Request for Social Security Earnings Information—0960-0525. The Social Security Act provides that a wage earner, or someone authorized by a wage earner, may request Social Security earnings information from the Social Security Administration, using form SSA-7050. SSA uses the information collected on the form to verify that the requestor is authorized to access the earnings record and to produce the earnings statement. The respondents are wage earners and organizations and legal representatives authorized by the wage earner.

Number of Respondents: 61,494.

Frequency of Response: 1.

Average Burden Per Response: 11 minutes.

Estimated Annual Burden: 11,274 hours.

9. Statement of Household Expenses and Contributions—0960-0456. Eligibility for SSI is based on need. A factor for determining need is whether an individual receives in-kind support and maintenance in the form of food and shelter provided by other persons. SSA collects information on form SSA-8011-F3 to determine the existence and amount of in-kind support and maintenance received by a claimant/beneficiary of SSI. SSA uses the information to determine eligibility and payment amount under this program. The respondents are members of SSI claimants'/beneficiaries' households.

Number of Respondents: 400,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 100,000 hours.

10. Payment of Certain Travel Expenses-0960-0434. This regulation (20 CFR 404.999 (d) and 416.1499) provides for travel expense reimbursement by the State agency or Federal agency for claimants traveling to a consultative examination, or for claimants, their representative and unsubpoenaed witnesses traveling over 75 miles to appear at a disability hearing. The claimant is required to submit an itemized list of actual travel expenses and supporting receipts which were incurred in order to attend a hearing or medical examination. State and Federal personnel review the listing and the receipts to verify the amount to be reimbursed to the claimant. The respondents are claimants for Title II/XVI benefits.

Number of Respondents: 50,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 8,333 hours.

Dated: August 6, 2001.

Frederick W. Brickenkamp,

Reports Clearance Officer.