01-29848. 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 and 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, DC 20503

(SSA)

Social Security Administration, DCFAM, Attn: Reports Clearance Officer 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. Information Collections Conducted by State Disability Determination Services (DDS) on Behalf of SSA—0960-0555. The State DDSs collect certain information to administer SSA's disability program. The information collected is as follows: (1) Medical evidence of record (MER)—DDSs use MER information to determine a person's physical and/or mental status prior to making a disability determination; (2) consultative exam (CE) medical evidence—DDSs use CE medical evidence to make disability determinations when the claimant's own medical sources cannot or will not provide the information; (3) CE claimant forms—The DDSs request that claimants complete an authorization form for the release of consultative exam information to a personal physician and to complete an appointment form to confirm scheduled CE appointments; (4) CE provider information—DDSs use the CE provider information to verify medical providers' credentials and licenses before hiring them to conduct CEs; (5) activities of daily living (ADL)—this information and other medical evidence are part of the evidentiary documentation used by the DDS's in evaluating a person's disability; and (6) pain information—this information is used by the DDSs to assess the effects of symptoms on functionality for determining disability. The respondents are medical providers, other sources of MER and disability claimants.

(1) MER (Respondents—Medical Providers and Other Sources)

Number of Responses: 6,052,494

Frequency of Response: Unknown

Average Burden Per Response: 15 minutes

Estimate Annual Burden: 1,513,124

(2) CE Medical Evidence (Respondents—Medical Providers)

Number of Responses: 1,640,269

Frequency of Response: Unknown

Average Burden Per Response: 30 minutes

Estimated Annual Burden: 820,135 hours

(3) CE Forms (Respondents—Claimants)

	Appointment form	Medical release
Number of Respondents:	820,134	1,640,269.
Frequency of Response:	1	1.
Average Burden Per Response:	5 minutes	5 minutes.
Estimated Annual Burden:	68,345 hours	136,689 hours.

(4) CE Providers (Respondents—Medical Providers)

Number of Responses: 3,000

Frequency of Response: 1

Average Burden: 20 minutes

Estimated Annual Burden: 1,000 hours

(5) ADL (Respondents—Claimants)

Number of Responses: 2,000,000

Frequency of Response: 1

Average Burden Per Response: 15 minutes

Estimated Annual Burden: 500,000 hours

(6) Pain (Respondents—Claimants)

Number of Responses: 1,000,000

Frequency of Response: 1

Average Burden Per Response: 15 minutes

Estimated Average Burden: 250,000 hours

2. Application for U.S. Benefits Under the Canada-U.S. International Agreement—0960-0371. The information collected on Form SSA-1294 is used to determine entitlement to benefits. The respondents are individuals who live in Canada and file for U.S. Social Security Benefits.

Number of Respondents: 1,000

Frequency of Response: 1

Average Burden Per Response: 15 minutes

Estimated Annual Burden: 250 hours

3. Disability Hearing Officer's Report of Disability Hearing (DC)—0960-0507. The information collected on form SSA-1204-BK is used by the Disability Hearing Officer (DHO) to conduct and document disability hearings, and to provide a structured format that concerns all conceivable issues relating supplemental security income claims for disabled children. The completed form SSA-1204-BK will aid the DHO in preparing the disability decision and will provide a record of what transpired at the hearing.

The respondents are DHO's in the State Disability Determination Services.

Number of Respondents: 100,000

Frequency of Response: 1

Average Burden Per Response: 60 minutes

Estimated Annual Burden: 100,000 hours

4. Statement of Death by Funeral Director—0960-0142. The Social Security Administration (SSA) uses the information on form SSA-721 to make timely and accurate decisions based on a report of death. The respondents are funeral directors with knowledge of the fact of death.

Number of Respondents: 1,059,400

Frequency of Response: 1

Average Burden Per Response: 4 minutes

Estimated Annual Burden: 70,627 hours

5. Statement Regarding Marriage—0960-0017. Form SSA-753 elicits information from third parties to verify the applicant's statements about intent, cohabitation, and holding out to the public as married, which are the basic tenets of a common-law marriage. The responses are used by SSA to determine if a valid marital relationship exists and to make an accurate determination regarding entitlement to spouse/widow(er) benefits. The respondents are individuals who are familiar with and can provide confirmation of an applicant's common-law marriage.

Number of Respondents: 40,000

Frequency of Response: 1

Average Burden Per Response: 9 minutes

Estimated Annual Burden: 6,000

6. Quarterly Statistical Report on Recipients and Payments Under State-Administered Assistance Programs for Aged, Blind, and Disabled (Individuals and Couples) Recipients—0960-0130. The information collected on Form SSA-9741 is used by States to provide statistical data on recipients and assistance payments under the SSI State-administered State Supplementation Programs. The data are needed to complement information available for the programs administered by SSA and to fully explain the impact of the public income support programs on the needy, aged, blind, and disabled. The respondents are State agencies who administer supplementary payment programs under SSI.

Number of Respondents: 30

Frequency of Response: 4

Average Burden Per Response: 60 minutes

Estimated Annual Burden: 2 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 on [phone], or by writing to him at the address listed above.

1. Modified Benefits Formula Questionnaire, Employer—0960-0477. Form SSA-58 is used by SSA to verify or disprove a claimant's allegation regarding a pension based on non-covered employment after 1956. It also shows whether that claimant was eligible for the pension before 1986. The respondents are persons who are eligible (after 1985) for both Social Security benefits and a pension from their employer, based on work not covered by SSA.

Number of Respondents: 30,000

Frequency of Response: 1

Average Burden Per Response: 20 minutes

Estimated Annual Burden: 10,000 hours

2. Application for Survivors Benefits—0960-0062. The information collected on Form SSA-24 is needed to satisfy the “Jointly Prescribed Application” of title 38 U.S.C. 5105. The provision requires that survivors who file with SSA or the VA shall be deemed to have filed with both agencies, and that each agency's forms must request information to constitute an application for both SSA and VA benefits. The respondents are survivors of military service veterans filing for Social Security benefits.

Number of Respondents: 3,200

Frequency of Response: 1

Average Burden Per Response: 15 minutes

Estimated Annual Burden: 800 hours

3. Medical Report (Individual With Childhood Impairment)—0960-0102. The information on Form SSA-3827-BK is needed to determine the claimant's physical and mental status prior to making a childhood disability determination. The respondents are medical sources.

Number of Respondents: 12,000

Frequency of Response: 1

Average Burden Per Response: 30 minutes

Estimated Annual Burden: 6,000 hours

4. Work Activity Report (Self-Employed)—0960-0598. Form SSA-820-F4 is used to determine whether work an individual performs in self-employment is at the substantial gainful activity (SGA) level. An individual's entitlement to benefits ends if he/she demonstrates an ability to perform SGA. The respondents are social security disability beneficiaries and Supplemental Security Income recipients.

Number of Respondents: 100,000

Frequency of Response: 1

Average Burden Per Response: 30 minutes

Estimated Annual Burden: 50,000 hours

5. Agreement to Sell Property—0960-0127. Form SSA-8060-U3 is used by SSA to document and ensure that individuals or couples who are otherwise eligible for Supplemental Security Income (SSI) payments, but who own in excess of the statutory limit, may receive conditional benefit payments if they agree to dispose of the excess resources and repay any overpayments with the proceeds of the disposition. The form is also used to ensure that the individuals understand their obligations under the agreement. The respondents are individuals (or couples) who are receiving (or will receive) conditional SSI payments.

Number of Respondents: 20,000

Frequency of Response: 1

Average Burden Per Response: 10 minutes

Estimated Annual Burden: 3,333 hours

6. Reconsideration Disability Report—0960-0144. SSA uses the information collected on Form SSA-3441 to determine if the claimant's medical or vocational situation changed after the initial disability determination, when the claimant requests a reconsideration of a denied disability claim. The form also elicits additional sources of medical and vocational evidence that were not considered in the initial determination. The respondents are disability beneficiaries who request a reconsideration of their claim.

Number of Respondents: 400,000

Frequency of Response: 1

Average Burden Per Response: 30 minutes

Estimated Average Burden: 200,000 hours

7. Electronic Benefit Verification Information—0960-0595. SSA provides verification of benefits, when requested, to individuals receiving title II and/or title XVI benefits. In order to provide to the public an easy and convenient means of requesting benefit information, SSA has developed an electronic request form that will allow persons to request the information through the Internet. The information collected on the electronic screens will be used by SSA to process the request for a benefit verification statement. To ensure appropriate confidentiality, the statement will be mailed to the recipient/beneficiary address shown in SSA's records. The respondents are title II and XVI recipients/beneficiaries who request benefit verification information using the Internet.

Number of Respondents: 133,920

Frequency of Response: 1

Average Burden Per Response: 1/2 minute

Estimated Average Burden: 1,116 hours

8. Statement by School Official About Student's Attendance; Statement to U.S. Social Security Administration By School Outside the United States About Student's Attendance—0960-0090. The information collected on Forms SSA-1371 and SSA-1371-FC is used by SSA to verify a student's alleged full-time attendance at an educational institution, in order to determine the student's eligibility for Social Security student benefits. The respondents are school officials who provide the information on these forms.

Number of Respondents: 5,000

Frequency of Response: 1

Average Burden Per Response: 10 minutes

Estimated Average Burden: 833 hours

9. Report of Continuing Disability Interview—0960-0072. SSA periodically reviews the cases of individuals who receive Social Security benefits and Supplemental Security Income (SSI) to determine if disability continues. During a review, SSA uses Form SSA-454-BK to collect information on disability. The information on the form is used to update the record of the disabled individual on recent medical treatment, vocational and educational experiences, work activity, and evaluations of potential for return to work. Based on this information and other evidence, SSA makes a determination on whether disability continues or has ended, and if so, when disability ended. The respondents are individuals who receive Social Security or SSI disability benefits, or their representatives.

Number of Respondents: 852,000

Frequency of Response: 1

Average Burden Per Response: 30 minutes

Estimated Annual Burden: 426,000 hours

Dated: November 26, 2001.

Nicholas E. Tagliareni,

Director, Center for Publications Management, Social Security Administration.