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 Public Law 104-13, the Paperwork Reduction Act of 1995, effective October 1, 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 mailed and/or faxed to the individuals at the addresses and fax numbers listed below:

(OMB), Office of Management and Budget, Attn: Desk Officer for SSA, Fax: 202-395-6974.

(SSA), Social Security Administration, DCFAM, Attn: Reports Clearance Officer, 1333 Annex Building, 6401 Security Blvd., Baltimore, MD 21235, Fax: 410-965-6400.

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. Function Report—Adult—Third Party—20 CFR 404.1512, 416.912—0960-0635. The information collected on the SSA-3380-BK is needed to make determinations on SSI and SSDI disability claims. This information is necessary for case development and adjudication, and is used by State Disability Determination Services evaluators as an evidentiary source used in the disability evaluation process. The respondents are third parties familiar with the functional limitations (or lack thereof) of claimants who apply for Social Security benefits and Supplemental Security Income disability payments.

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

Number of Respondents: 1,000,000.

Frequency of Response: 1.

Average Burden per Response: 60 minutes.

Estimated Annual Burden: 1,000,000 hours.

2. Request for Internet Services—Password Authentication—20 CFR 401.45—0960-0632. SSA has established a Password infrastructure for using its Internet and Automated Telephone Response services to access SSA records. These services are password protected due to the nature of the information being transmitted or because the requested information requires a higher level of protection to ensure the security and confidentiality of records. Password Authentication is used to establish a password process for verifying the identity of individuals who choose to use these services for conducting business with SSA. Individuals are required to provide identifying information to SSA, such as their name, social security number, date of birth, and a shared secret between themselves and SSA before they can create a password. After this information is stored and verified, SSA sends the individual their new personal identification number (PIN) and password to be used to access SSA's password protected services. The password process allows requestors to establish their identities with SSA and create a password which they can then use to access their own personal information. The respondents are persons electing to do business with SSA through an electronic medium.

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

Number of Respondents: 1,630,771.

Frequency of Response: 1.

Average Burden per Response: 10 minutes.

Estimated Annual Burden: 271,795 hours.

3. Statement of Reclamation Action—31 CFR 210—0960-NEW. Form SSA-1713 collects information regarding whether, how and when a Canadian bank was able to return erroneous payments made after the death of a beneficiary who elected to have payments sent to Canada. The SSA-1713 is sent with the SSA-1712, an SSA-generated cover sheet which provides the Canadian bank with information regarding the deceased beneficiary. In this way, SSA can reclaim funds which were erroneously paid. The respondents are Canadian financial institutions to which Social Security payments have been made.

Type of Request: Existing Information Collection in Use Without an OMB Number.

Number of Respondents: 15.

Frequency of Response: 1.

Average Burden per Response: 5 minutes.

Estimated Annual Burden: 1 hour.

4. Request for Reconsideration—Disability Cessation— 20 CFR 404.909, 416.1409—0960-0349. Form SSA-789-U4 is used by claimants to request reconsideration of a determination and to indicate whether or not they wish to appear at a disability hearing. This form can also be used to submit any additional information/evidence for use in the reconsidered determination and to indicate if an interpreter is needed for the hearing. SSA will use this information to either arrange for a hearing or to prepare a decision based on the evidence of record. The respondents are applicants or claimants for Social Security benefits or SSI payments.

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

Number of Respondents: 49,000.

Frequency of Response: 1.

Average Burden per Response: 13 minutes.

Estimated Annual Burden: 10,617 hours

5. Representative Payment Policies Regulation—20 CFR 404.2011, 404.2025, 416.611, 416.625—0960-0679. In cases where SSA determines that it is not in a beneficiary's best interest to receive payments directly as it may cause substantial harm, the beneficiaries may dispute this decision. If they do, they provide SSA with information which SSA will take into consideration when reevaluating the decision. Representative payees must also provide SSA with information regarding their relationship, responsibility, and how payments were used for the beneficiary. Respondents are beneficiaries and representative payees.

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

Estimated Annual Burden: 363 hours.

6. Psychiatric Review Technique—20 CFR 404.1520(a), 416.920(a)—0960-0413. The SSA-2506-BK assists the DDSs in evaluating mental impairments by helping to: organize and present the mental findings in a clear, concise and consistent manner; consider and evaluate all aspects of the mental impairment relevant to the individual's ability to perform work-related mental functions; and identify additional evidence needed to determine impairment severity. The respondents are the 52 State DDSs administering the Title II and Title XVI programs.

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

Number of Respondents: 52.

Frequency of Response: 20,595.

Total Annual Responses: 1,070,940.

Average Burden per Response: 15 minutes.

Estimated Annual Burden: 267,735 hours.

7. Disability Hearing Officer's Decision—Title XVI Disabled Child (DC) Continuing Disability Review—20 CFR 404.913-.914, 404.917, 416.994a, 416.1413-.1414, 416.1417—0960-0657. Form SSA-1209-BK is used by the disability hearing officer conducting the disability hearing to prepare and issue a written reconsidered determination—specifically for evaluating Title XVI childhood disability cases. The form provides the framework for addressing the crucial elements of the case in a sequential and logical fashion, and the completed form is the official document of the decision. Respondents are disability hearing officers in State Disability Determination Services (DDSs).

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

Number of Respondents: 35,000.

Frequency of Response: 1.

Average Burden per Response: 75 minutes.

Estimated Annual Burden: 43,750 hours.

8. Certificate of Incapacity—5 CFR 890.302(d)—0960-NEW. Rules governing the Federal Employee Health Benefits (FEHB) plan state that for federal employees' children ages 22 or over to retain health benefits, they must be incapable of self-support due to a disability that (1) pre-dated the child's 22nd birthday, (2) is very serious, and (3) can be expected to last at least one year. Form SSA-604, the Certificate of Incapacity, is used by physicians to document and certify such a disability for their patients who are children of Federal employees. The respondents are physicians of federal employees' children ages 22 or over who are seeking to retain health benefits under their parent's FEHB coverage.

Type of Request: New information collection.

Number of Respondents: 38.

Frequency of Response: 1.

Average Burden per Response: 45 minutes.

Estimated Annual Burden: 29 hours.

9. Function Report—Adult—20 CFR 404.1512 and 419.912—0960-0681. Form SSA-3373 is used to collect information about a disability applicant's impairment-related limitations and ability to function. It documents the types of information specified in SSA regulations and provides disability interviewers 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 disability process is founded. The respondents are Title II and Title XVI benefits applicants.

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

Number of Respondents: 4,005,367.

Frequency of Response: 1.

Average Burden per Response: 60 minutes.

Estimated Annual Burden: 4,005,367.

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 at 410-965-0454, or by writing to the address listed above.

1. Statement of Employer—20 CFR 404.801-803—0960-0030. The information collected on Form SSA-7011—F4 is needed to substantiate allegations of wages paid to workers when wages do not appear in SSA's records of earnings and the worker has no proof of said earnings. SSA can use the information to process claims for benefits and resolve discrepancies in the worker's earnings record. The respondents are certain employers who can verify wage allegations made by the wage earner.

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

Number of Respondents: 925,000.

Frequency of Response: 1.

Average Burden per Response: 20 minutes.

Estimated Annual Burden: 308,333 hours.

2. Request for Workers' Compensation/Public Disability Benefit Information—20 CFR 404.408(e)—0960-0098. Section 224 of the Social Security Act provides for an offset of disability insurance benefits when workers' compensation (WC) or public disability benefits (PDB) is also being received. The SSA-1709 is used to request and/or verify information regarding WC/PDB given to Social Security disability recipients so that the proper adjustment is made to their monthly benefits. The respondents are Federal, State, and local agencies administering WC/PDB, insurance carriers, and public or private self-insured companies.

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

Number of Respondents: 120,000.

Frequency of Response: 1.

Average Burden per Response: 15 minutes.

Estimated Annual Burden: 30,000 hours.

3. Disability Report-Appeal—20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c)—0960-0144. The SSA-3441-BK is used to secure updated resource and condition information from claimants seeking reconsideration of denied disability benefits. The claimant also has the option of providing the information during a personal interview or through SSA's Internet application. This information assists the State Disability Determination Services and administrative law judges in preparing for appeals and hearings and in issuing a decision. Respondents are individuals who appeal denial of Social Security disability income and Supplemental Security Income (SSI) benefits, cessation of benefits, or who are requesting a hearing.

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

Estimated Annual Burden: 924,967 hours.

4. Third Party Liability Information Statement—42 CFR 433.136-433.139—0960-0323. Identification of sources of third party insurance liable for medical care or services for Medicaid beneficiaries, which could be used to reduce Medicaid costs, is required under 42 U.S.C. 1396a(a)(25). Medicaid State agencies are mandated under 42 CFR 433.136-.139 to obtain this information on Medicaid applications and redeterminations as a condition of Medicaid eligibility. States are permitted to enter into agreements with the Commissioner of Social Security to make Medicaid eligibility determinations for aged, blind and disabled beneficiaries in those States. Applications for and redeterminations of SSI eligibility in jurisdictions with such agreements are also applications and redeterminations of Medicaid eligibility. Under these agreements, SSA obtains third party liability information using form SSA-8019 and provides that information to the State agencies which provide Medicaid under the terms of an approved plan in Title XIX of the Social Security Act. The Medicaid State agencies then use the information provided to attempt to bill any third parties liable for medical care, support or services for a beneficiary to guarantee that Medicaid remains the payer of last resort. The respondents are SSI applicants and beneficiaries.

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

Number of Respondents: 73,540.

Frequency of Response: 1.

Average Burden per Response: 5 minutes.

Estimated Annual Burden: 6,128 hours.

5. Claimant Statement About Loan of Food or Shelter; Statement About Food or Shelter Provided to Another—20 CFR 416.1130-416.1148—0960-0529. Forms SSA-5062 and SSA-L5063 are used to obtain statements about food and/or shelter provided to an SSI claimant or recipient. SSA uses this information to determine whether food and/or shelter are bona fide loans or should be counted as income for SSI purposes. This determination can affect eligibility for SSI and the amount of SSI benefits payable. The respondents are claimants/recipients for SSI benefits and individuals that provide loans of food and/or shelter to SSI claimants/recipients.

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

Estimated Annual Burden: 21,846 hours.