[Federal Register Volume 66, Number 232 (Monday, December 3, 2001)]
[Notices]
[Pages 60234-60237]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 01-29848]


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SOCIAL SECURITY ADMINISTRATION


Agency Information Collection Activities: Proposed Request and 
Comment Request

    The Social Security Administration (SSA) publishes a list of 
information

[[Page 60235]]

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

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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 (410) 965-
4145, 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,

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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.
[FR Doc. 01-29848 Filed 11-30-01; 8:45 am]
BILLING CODE 4191-02-U