[Federal Register Volume 60, Number 135 (Friday, July 14, 1995)]
[Notices]
[Pages 36326-36327]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-17305]



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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 
P.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 June 16, 1995.

    (Call Reports Clearance Officer on (410) 965-4142 for copies of 
package.)

    1. Certificate of Coverage Request--0960-NEW. The information is 
used by the Social Security Administration to provide a certificate of 
coverage from the United States social security system to an individual 
working in a foreign country. This certificate exempts the individual 
from paying taxes into a foreign social security system. The 
respondents are workers and employers whose work is performed in a 
foreign country.

Number of Respondents: 24,000
Frequency of Response: 1
Average Burden Per Response: 30 minutes
Estimated Annual Burden: 12,000 hours

    2. Disability Report, Vocational Report--0960-0141. The information 
on forms SSA-3368 and SSA-3369 is used by the Social Security 
Administration to help make a disability determination. The forms are 
essential to case development and adjudication. The respondents are 
individuals who file for disability benefits.

------------------------------------------------------------------------
                                            SSA-3368         SSA-3369   
------------------------------------------------------------------------
Number of Respondents.................  2,264,000......  1,000,000      
Frequency of Response.................  1..............  1              
Average Burden Per Response...........  45 minutes.....  30 minutes     
Estimated Annual Burden...............  1,698,000 hrs..  500,000 hrs.   
------------------------------------------------------------------------

    3. SSA Automated SML Application--0960-0475. The information on 
form SSA-4123 is used to maintain an automated solicitation mailing 
list of qualified vendors wanting to do business with the Social 
Security Administration (SSA). The respondents are vendors who wish to 
be listed on SSA's automated solicitation mailing list.

Number of Respondents: 4,000
Frequency of Response: 1
Average Burden Per Response: 5 minutes
Estimated Annual Burden: 333 hours

    4. Social Security Medical Report (General)--0960-0052. The 
information on form SSA-3826 is used by the Social Security 
Administration to determine the claimant's physical status prior to 
making a disability determination. The information is used to document 
disability claims folders with medical evidence.

Number of Respondents: 750,000
Frequency of Response: 1
Average Burden Per Response: 30 minutes
Estimated Annual Burden: 375,000 hours

    5. Request for Social Security Earnings Information--0960-0525. The 
information on form SSA-7050 is used by the Social Security 
Administration (SSA) to identify the request, define the earnings 
information being requested, and inform the requestor of the fee for 
such information. The above data is then used by SSA to produce the 
requested statement. The respondents are individuals and organizations 
which use this form to request statements of earnings from SSA.

Number of Respondents: 40,000
Frequency of Response: 1
Average Burden Per Response: 11 minutes
Estimated Annual Burden: 7,333 hours

    6. Employee Identification Statement--0960-0473. The information on 
form SSA-4156 is used by the Social Security Administration to resolve 
situations in which two or more individuals have used the same social 
security number (SSN) and an employer has erroneously reported earnings 
under an SSN. The affected public is comprised of employers involved in 
erroneous wage reporting.

Number of Respondents: 4,750
Frequency of Response: 1
Average Burden Per Response: 10 minutes
Estimated Annual Burden: 792 hours

    7. Report of Work Activity--Continuing Disability--0960-0108. The 
information on form SSA-3945 is used by the Social Security 
Administration to determine whether work performed by an individual, 
after his or her entitlement to disability benefits, is cause for that 
entitlement to end. The affected public consists of disability 
beneficiaries who work after their entitlement.

Number of Respondents: 140,000
Frequency of Response: 1
Average Burden Per Response: 45 minutes
Estimated Annual Burden: 105,000 hours

    8. Medical History and Disability Report--0960-0504. The 
information on form SSA-3820 is used by the Social Security 
Administration to help make a determination in claims for disabled 
children. The respondents are claimants for disability benefits.

Number of Respondents: 453,000
Frequency of Response: 1
Average Burden Per Response: 20 minutes
Estimated Annual Burden: 151,000 hours

    9. Statement Regarding Student's Attendance--0960-0113. The 
information on form SSA-2434 is used 

[[Page 36327]]
by the Social Security Administration to determine student status of 
the children of coal miners or their widows or brothers of deceased 
coal miners eligible for black lung benefits.

Number of Respondents: 4,340
Frequency of Response: 1
Average Burden Per Response: 10 minutes
Estimated Annual Burden: 723 hours

    10. Summary of Evidence--0960-0430. The information on form SSA-887 
is used to provide a list of the medical/vocational reports pertaining 
to the claimant's disability. The list is used in and critical to the 
hearings process. The respondents are State and Disability 
Determination staff.

Number of Respondents: 22,024
Frequency of Response: 1
Average Burden Per Response: 15 minutes
Estimated Annual Burden: 5,506 hours

    11. Request For Change In Time/Place of Disability Hearing-- 0960-
0348. The information on form SSA-769 is used to provide claimants a 
structured format for exercising their right to request a change in the 
time or place of a scheduled disability hearing. The information will 
be used as a basis for granting or denying requests for changes and for 
rescheduling hearings. The affected public is comprised of claimants 
who wish to request a change in the time or place.

Number of Respondents: 7,483
Frequency of Response: 1
Average Burden Per Response: 8 minutes
Estimated Annual Burden: 998 hours

    12. Time Report of Personnel Services for Disability Determination 
Services--0960-0408. The information on form SSA-4514 is used by the 
Social Security Administration (SSA) for budgeting and accounting for 
the funds used by State Agencies for personnel involved in making 
disability determinations for SSA. The affected public consists of 
State Agencies which make those determinations.

Number of Respondents: 54
Frequency of Response: Quarterly
Average Burden Per Response: 30 minutes
Estimated Annual Burden: 108 hours

    13. Payment of Certain Travel Expenses--0960-0504. The information 
required by 20 CFR 404.999(d) and 20 CFR 416.1499 is used by the Social 
Security Administration to reimburse a claimant who has been required 
to travel over 75 miles to appear at a medical examination or 
disability hearing. The affected public is comprised of claimants 
required to travel more than 75 miles in order to attend a medical 
examination or a disability hearing.

Number of Respondents: 50,000
Frequency of Response: 1
Average Burden Per Response: 10 minutes
Estimated Annual Burden: 8,333 hours

    14. Request for Reconsideration--Disability Cessation--0960-0504. 
The information on form SSA-789 is used by the Social Security 
Administration to schedule hearings and to develop additional evidence 
for individuals who have received an initial or revised determination 
that their disability ceased, did not exist, or is no longer disabling. 
The respondents are disability beneficiaries who file a claim for 
reconsideration.

Number of Respondents: 15,015
Frequency of Response: 1
Average Burden Per Response: 12
Estimated Annual Burden: 3,003

    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: July 7, 1995.
Charlotte Whitenight,
Reports Clearance Officer, Social Security Administration.
[FR Doc. 95-17305 Filed 7-13-95; 8:45 am]
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