[Federal Register Volume 59, Number 194 (Friday, October 7, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-24767]


[[Page Unknown]]

[Federal Register: October 7, 1994]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Social Security Administration

 

Agency Forms Submitted to the Office of Management and Budget for 
Clearance

    Normally on Fridays, the Social Security Administration publishes a 
list of information collection packages that have been submitted to the 
Office of Management and Budget (OMB) for clearance in compliance with 
Pub. L. 96-511, The Paperwork Reduction Act. The following clearance 
packages have been submitted to OMB since the last list was published 
in the Federal Register on Friday, September 9, 1994. (Call Reports 
Clearance Officer on (410) 965-4142 for copies of package.)
    1. Disability Report and Disability Report (Short Form)--0960-0141. 
The information on revised forms SSA-3368 and 3368A will be used by the 
Social Security Administration to help make a disability determination. 
The respondents will be individuals who file for disability benefits. 

------------------------------------------------------------------------
                                         SSA-3368           SSA-3368A   
------------------------------------------------------------------------
Number of Respondents.............  2,164,000.........  100,000         
Frequency of Response.............  1.................  1               
Average Burden Per Response.......  30 minutes........  10 minutes      
Estimated Annual Burden...........  1,082,000 hrs.....  16,667 hours    
------------------------------------------------------------------------

    2. Work History Report--0960-0141. The information on revised form 
SSA-3369 will be used by the Social Security Administration to record 
information about a claimant's work history in order to help make a 
disability determination. The respondents will be individuals who file 
for disability benefits.

Number of Respondents: 1,000,000
Frequency of Response: 1
Average Burden Per Response: 30 minutes
Estimated Annual Burden: 500,000 hours

    3. Pain Questionnaire-Adult--Child--0960-NEW. The information on 
forms SSA-3370 and 3371 will be used by the Social Security 
Administration to obtain the types of information specified in the 
regulations and to provide disability interviewers (and claimants in 
self-help situations) with a convenient means to record information 
about the claimant's allegations of pain, how the pain affects his or 
her ability to function in a work setting, or in the case of a child, 
the ability to perform age-appropriate activities. The respondents will 
be claimants for disability benefits.

Number of Respondents: 1,000,000 (total for both forms)
Frequency of Response: 1
Average Burden Per Response: 15 minutes
Estimated Annual Burden: 250,000 hours

    4. Report of Function-Adult--0960-NEW. The information on form SSA-
3373 will be used by the Social Security Administration to record 
information about how the claimant's condition affects his or her 
ability to function. The respondents will be claimants for disability 
benefits.

Number of Respondents: 2,264,000
Frequency of Response: 1
Average Burden Per Response: 15 minutes
Estimated Annual Burden: 566,000 hours

    5. Disability Report-Child--0960-0504. The information on the 
revised form SSA-3820 will be used by the Social Security 
Administration to help make a disability determination in claims for 
benefits. The respondents will be parents or guardians who file for 
such benefits on behalf of a child. 

------------------------------------------------------------------------
                                         SSA-3820          SSA-3820A    
------------------------------------------------------------------------
Number of Respondents.............  513,000...........  10,000          
Frequency of Response.............  1.................  1               
Average Burden Per Response.......  40 minutes........  10 minutes      
Estimated Annual Burden...........  342,000 hours.....  1,667 hours     
------------------------------------------------------------------------

    6. Plan for Achieving Self-Support (PASS) study form. The 
information on the questionnaire will be used by the Social Security 
Administration to determine the effectiveness of the Agency's 
implementation, monitoring, and control of the PASS activities. The 
study form will be used to obtain various PASS information from 
Supplemental Security Income recipients.

Number of Respondents: 1,900
Frequency of Response: 1
Average Burden Per Response: 20 minutes
Estimated Annual Burden: 633 hours

    OMB Desk Officer: Laura Oliven.
    Written comments and recommendations regarding these information 
collections should be sent directly to the appropriate OMB Desk Officer 
designated above at the following address: Office of Management and 
Budget, OIRA New Executive Office Building, Room 10230, Washington, 
D.C. 20503.

    Dated: September 30, 1994.
Charlotte Whitenight,
Reports Clearance Officer, Social Security Administration.
[FR Doc. 94-24767 Filed 10-6-94; 8:45 am]
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