[Federal Register Volume 67, Number 22 (Friday, February 1, 2002)]
[Notices]
[Pages 5029-5031]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-2429]


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SOCIAL SECURITY ADMINISTRATION


Agency Information Collection Activities: Notice of Office of 
Management and Budget (OMB) Approval, Proposed Request and Comment 
Request

ACTION: Notice of OMB Approval

    As required by the Paperwork Reduction Act of 1995 (44 U.S.C. 
3507), the Social Security Administration (SSA) is providing notice of 
OMB's approval of the information collections in the final rule, 
Revised Medical Criteria for Determination of Disability, 
Musculoskeletal System and Related Criteria, part 404, subpart, 
appendix 1. In accordance with the Paperwork Reduction Act, persons are 
not required to respond to an information collection unless it displays 
a valid Office of Management and Budget control number. The OMB Number 
is 0960-0642, which expires December 31, 2004.

ACTION: 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 410-965-0454, or by 
writing to the address listed above.
    1. Employee Work Activity Report--0960-0483. The data collected by 
the Social Security Administration on Form SSA-3033 is reviewed and 
evaluated to determine if the claimant meets the disability 
requirements of the law, when the claimant returns to work after the 
alleged or established onset date of disability. When a possible 
unsuccessful work attempt or nonspecific subsidy is involved (and the 
information cannot be obtained through telephone contact), Form SSA-
3033 will be used to request a description, by mail, of the employee's 
work effort. The respondents are employers of Old Age, Survivors and 
Disability Insurance and Supplemental

[[Page 5030]]

Security Income disability applicants and beneficiaries.
    Number of Respondents: 12,500.
    Frequency of Response: 1.
    Average Burden Per Response: 15 minutes.
    Estimated Annual Burden: 3,125 hours.
    2. State Agency Ticket Assignment Form, SSA-1365, State Vocational 
Rehabilitation Ticket to Work Information Sheet, SSA-1366 and 
Individual Work Plans (IWP) Information Sheet, SSA-1367--0960-0641.

Background

    Public Law (Pub. L.) 106-170, the Ticket to Work and Work 
Incentives Improvement Act of 1999, created a new Ticket to Work (TTW) 
program for providing work access services to SSA beneficiaries. The 
new program requires SSA to monitor the services provided under the 
Law. SSA has developed three data collection forms that request service 
provider and beneficiary information, which is essential to SSA's 
administration of this new program. Employment networks (ENs) providing 
TTW services under contracts with SSA are required to submit to SSA the 
information listed in form SSA-1367. State vocational rehabilitation 
agencies (VRAs) that provide services to SSA beneficiaries under either 
the traditional VR reimbursement mechanism or the new TTW program are 
required to submit to SSA the information listed in forms SSA-1365 and 
SSA-1366. SSA does not require that ENs or VRAs use forms SSA-1366 and 
SSA-1367 per se, but does require that any alternative forms submitted 
in place of these SSA forms include the SSA listed information at a 
minimum. VRAs are required to submit Form SSA-1365 in all cases as a 
means of assigning Tickets to VRAs.
    a. State Agency Ticket Assignment Form--SSA-1365. The information 
collected on this form will be used by SSA's contracted Program Manager 
(PM) to perform the task of assigning beneficiaries' tickets and 
monitoring the use of tickets under the Ticket to Work and Self-
Sufficiency Program. The State VRA answers the questions and the 
beneficiary reviews the data and if in agreement will sign the form 
acknowledging the Ticket assignment. The respondents are State VR 
agencies.
    Number of Respondents: 21.
    Frequency of Response: 4,048 annually per respondent.
    Average Burden Per Response: 3 minutes.
    Estimated Annual Burden: 4,250 hours.
    b. State Vocational Rehabilitation Ticket to Work Information 
Sheet-SSA-1366. The information collected on Form SSA-1366 will be used 
by SSA's contracted PM when a State VRA elects to participate in the 
Program as an EN. In this case, form SSA-1366, when combined with the 
SSA-1365, is intended to meet the minimum information requirements for 
IWPs and to monitor the appropriateness of the IWPs as required under 
the Pub. L. 106-107. The respondents are VRAs acting as ENs under the 
Ticket to Work Program.
    Number of Respondents: 21.
    Frequency of Response: 132 annually per respondent.
    Average Burden Per Response: 2 minutes.
    Estimated Annual Burden: 92 hours.

    Please Note:
    The Ticket to Work Program is being implemented in stages. The 
above represents the initial phase of the program with 13 
participating states that include 21 State VR agencies. As the 
program continues to be phased in, each initial program year will 
result in a larger number of new tickets for the participating State 
VRs because existing clients will also be brought into the program.

    c. Individual Work Plans (IWP) Information Sheet-SSA-1367. The 
information collected on Form SSA-1367 will be used to monitor the 
appropriateness of IWPs that have been assigned to ENs under the TTW 
program. The respondents are ENs under the TTW program.
    Number of Respondents: 31,450.
    Frequency of Response: 1 annually per respondent.
    Average Burden Per Response: 3 minutes.
    Estimated Annual Burden: 1,573 hours.
    4. Statement Regarding the Inferred Death of an Individual By 
Reason of Continued and Unexplained Absence--0960-0002. The information 
collected on Form SSA-723-F4 is needed to determine if SSA may presume 
that a missing wage earner is dead and, if so, to establish a date of 
presumed death. The respondents are people who have knowledge of the 
disappearance of the wage earner.
    Number of Respondents: 3,000.
    Frequency of Response: 1.
    Average Burden Per Response: 30 minutes.
    Estimated Annual Burden: 1,500 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 package 
by calling the SSA Reports Clearance Officer on (410) 965-0454, or by 
writing to the address listed above.
    1. Information Collections Conducted by State Disability 
Determination Services (DDS) on Behalf of SSA--0960-0555. The State 
DDS's collect certain information to administer SSA's disability 
program. The information collected is as follows: (1) Medical evidence 
of record (MER)--DDS's 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--DDS's 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 DDS's 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--
DDS's 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 DDS's to assess the effects of symptoms on 
functioning 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)

[[Page 5031]]



------------------------------------------------------------------------
                                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. 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.
    4. 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 being 
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.
    5. 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 by SSA 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. SSA personnel request 
data about State-administered supplementation programs to compare 
various State programs, to examine the relationship of State 
supplementation expenditures and caseloads to federally-financed 
programs such as Medicaid, and to determine the effect of changes in 
SSI and other Federal programs on State supplementation programs. 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: 120 hours.

    Dated: January 28, 2002.
Elizabeth A. Davidson,
Acting Reports Clearance Officer, Social Security Administration.
[FR Doc. 02-2429 Filed 1-31-02; 8:45 am]
BILLING CODE 4191-02-U