[Federal Register Volume 69, Number 23 (Wednesday, February 4, 2004)]
[Notices]
[Pages 5380-5383]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-2215]


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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 collection packages that will require clearance by the 
Office of Management and Budget (OMB) in compliance with Pub. L. 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, New 
Executive Building, Room 10235, 725 17th St., NW., Washington, DC 
20503, Fax: 202-395-6974.
(SSA), Social Security Administration, DCFAM, Attn: Reports Clearance 
Officer, 1338 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. Application Statement for Child's Insurance Benefits--20 CFR 
404.350-.368, 404.603, and 416.350--0960-0010. Title II of the Social 
Security Act provides for payment of monthly benefits to the children 
of an insured retired, disabled, or deceased worker, if certain 
conditions are met. The form SSA-4-BK is used by SSA to collect 
information needed to determine whether the child or children are 
entitled to benefits. The respondents are children of the worker or 
individuals who complete this form on their behalf.
    Type of Request: Extension of an OMB-approved information 
collection.

------------------------------------------------------------------------
                                     Life claims         Death claims
------------------------------------------------------------------------
Number of Respondents..........  925,000............  815,000.
Frequency of Response..........  1..................  1.
Average Burden Per Response....  10.5 minutes.......  15.5 minutes.
Estimated Annual Burden........  161,875 hours......  210,542 hours.
------------------------------------------------------------------------

    2. Physician's/Medical Officer's Statement of Patient's Capability 
to Manage Benefits--20 CFR 404.2015 and 416.615--0960-0024. SSA uses 
the information collected on form SSA-787 to determine an individual's 
capability, or lack thereof, to handle his or her own benefits. This 
information also provides SSA with a means of selecting a 
representative payee, if this proves necessary. The respondents are 
beneficiaries' physicians.
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 120,000.
    Frequency of Response: 1.
    Average Burden Per Response: 10 minutes.
    Estimated Annual Burden: 20,000 hours.
    3. Physical Residual Functional Capacity Assessment and Mental 
Residual Functional Capacity Assessment--20 CFR 404.1545 and 416.945--
0960-0431. The information collected by form SSA-4734 is used in the 
adjudication of disability claims involving physical and/or mental 
impairments. The form provides the State Disability Determination 
Service (DDS) with a standardized data collection format to evaluate 
impairment(s) and to present findings in a clear, concise, and 
consistent manner. The respondents are State DDSs administering Title 
II and Title XVI disability programs.
    Type of Request: Extension of an OMB-approved information 
collection.

------------------------------------------------------------------------
                                     SSA-4734-BK         SSA-4734-SUP
------------------------------------------------------------------------
Number of Respondents..........  1,625,095..........  796,770.
Frequency of Response..........  1..................  1.
Average Burden Per Response....  20 minutes.........  20 minutes.
Estimated Annual Burden........  541,698 hours......  265,590 hours.
------------------------------------------------------------------------

    4. Social Security Benefits Applications--20 CFR Subpart D,

[[Page 5381]]

404.310-404.311 and 20 CFR Subpart F, 404.601-401.603--0960-0618. One 
of the requirements for obtaining Social Security benefits is the 
filing of an application so that a determination may be made on the 
applicant's eligibility for monthly benefits. In addition to the 
traditional paper application, SSA has developed various options for 
the public to add convenience and operational efficiency to the 
application process. The total estimated number of respondents to all 
application collections formats is 3,843,369 with a cumulative total of 
995,457 burden hours. The respondents are applicants for RIB, DIB, and/
or spouses' benefits.
    Please note that burden hours for applications taken through the 
Modernized Claims System (MCS) are accounted for in the hardcopy 
collection formats. MCS is an electronic collection method that mirrors 
the hardcopy application formats. Guided by the MCS collection screens, 
an SSA representative interviews the applicant and inputs the 
information directly into SSA's application database. MCS offers the 
representative prompts based on the type of application being filed and 
the circumstances of the applicant. These prompts facilitate a more 
complete initial application, saving both the agency and applicant 
time. MCS also propagates identity and similar information within the 
application, which saves additional time.
    Type of Request: Revision of an OMB-approved information collection 
(ISBA collection only).

Internet Social Security Benefits Application (ISBA)

    ISBA, which is available through SSA's Internet site, is one method 
that an individual can choose to file an application for benefits. 
Individuals can use ISBA to apply for retirement insurance benefits 
(RIB), disability insurance benefits (DIB) and spouse's insurance 
benefits based on age. SSA gathers only information relevant to the 
individual applicant's circumstances and will use the information 
collected by ISBA to entitle individuals to RIB, DIB, and/or spouses' 
benefits. The respondents are applicants for RIB, DIB, and/or spouses 
benefits.
    Number of Respondents: 169,000.
    Frequency of Response: 1.
    Average Burden Per Response: 21.4 minutes.
    Estimated Annual Burden: 60,277 hours.

Paper Application Forms

Application for Retirement Insurance Benefits (SSA-1)

    The SSA-1 is used by SSA to determine an individual's entitlement 
to retirement insurance benefits. In order to receive Social Security 
retirement insurance benefits, an individual must file an application 
with the SSA. The SSA-1 is one application that the Commissioner of 
Social Security prescribes to meet this requirement. The information 
that SSA collects will be used to determine entitlement to retirement 
benefits. The respondents are individuals who choose to apply for 
Social Security retirement insurance.
    Number of Respondents: 1,460,692.
    Frequency of Response: 1.
    Average Burden Per Response: 10.5 minutes.
    Estimated Annual Burden: 255,621 hours.

Application for Wife's or Husband's Insurance Benefits (SSA-2)

    SSA uses the information collected on Form SSA-2 to determine if an 
applicant (including a divorced applicant) can be entitled to benefits 
as the spouse of the worker and the amount of the spouse's benefits. 
The respondents are applicants for wife's or husband's benefits, 
including those who are divorced.
    Number of Respondents: 700,000.
    Frequency of Response: 1.
    Average Burden Per Response: 15 minutes.
    Estimated Annual Burden: 175,000 hours.

Application for Disability Insurance Benefits (SSA-16)

    Form SSA-16-F6 obtains the information necessary to determine 
whether the provisions of the Act have been satisfied with respect to 
an applicant for disability benefits, and detects whether the applicant 
has dependents who would qualify for benefits on his or her earnings 
record. The information collected on form SSA-16 helps to determine 
eligibility for Social Security disability benefits. The respondents 
are applicants for Social Security disability benefits.
    Number of Respondents: 1,513,677.
    Frequency of Response: 1.
    Average Burden Per Response: 20 minutes.
    Estimated Annual Burden: 504,559 hours.
    5. Youth Transition Process Demonstration Evaluation Data 
Collection--0960-NEW. To further the President's New Freedom Initiative 
goal of increasing employment for individuals with disabilities, SSA 
plans to award seven cooperative agreements for the purpose of 
developing service delivery systems to assist youth with disabilities 
to successfully transition from school to work. SSA is funding two 
coordinated contracts to provide (1) technical assistance and (2) an 
evaluation. SSA will work with the Evaluation Contractor to use the 
results to conduct a net outcome evaluation to determine the long-term 
effectiveness of the interventions, impacts, and benefits of the 
demonstration. Evaluation data will be used by the projects to improve 
the efficiency of the project's operations; use of staff; linkages 
between the project and the agencies through which comprehensive 
services are arranged; and specific aspects of service delivery to 
better meet the needs of the targeted population. This type of project 
is authorized by sections 1110 and 234 of the Social Security Act. The 
respondents will be youth with disabilities who have enrolled in this 
project.
    Type of Request: New information collection.
    Number of Respondents: 5,000.
    Frequency of Response: 4.
    Average Burden Per Response: 15 minutes.
    Estimated Annual Burden: 5,000 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 at 410-965-0454, 
or by writing to the address listed above.
    1. Certificate of Support--20 CFR 404.408a, 44.370, and 404.750--
0960-0001. The information collected by form SSA-760-F4 is used to 
determine whether a deceased worker provided the one-half support 
required for entitlement to parent's or spouse's Social Security 
benefits. The information will also be used to determine whether the 
Government pension offset would apply to the applicant's benefit 
payments. The respondents are parents of deceased workers or spouses 
who may be subject to the Government pension offset.
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 18,000.
    Frequency of Response: 1.
    Average Burden Per Response: 15 minutes.
    Estimated Annual Burden: 4,500 hours.

[[Page 5382]]

    2. Notice Regarding Substitution of Party Upon Death of Claimant--
20 CFR 404.957(c)(4) and 416.1457(c)(4)--0960-0288. When a claimant for 
Social Security or Supplemental Security Income benefits dies while a 
request for a hearing is pending, the hearing will be dismissed unless 
an eligible individual makes a written request to SSA showing that he 
or she would be adversely affected by the dismissal of the deceased's 
claim. An individual may satisfy this requirement by completing an HA-
539. SSA uses the information collected to document the individual's 
request to be made a substitute party for a deceased claimant, and to 
make a decision on whom, if anyone, should become a substitute party 
for the deceased. The respondents are individuals requesting hearings 
on behalf of deceased claimants for Social Security benefits.
    Type of Request: Extension of an OMB-approved information 
collection.
    Number of Respondents: 10,548.
    Frequency of Response: 1.
    Average Burden Per Response: 5 minutes.
    Estimated Annual Burden: 879 hours.
    3. Benefits Planning, Assistance, and Outreach (BPAO) Program--
0960-0629.

Background

    SSA awarded cooperative agreements to establish community-based 
benefits planning, assistance, and outreach projects in every State and 
U.S. Territory, as it is authorized to do under Section 1149 of the 
Social Security Act. Potential awardees were State and local 
governments, public and private organizations, and nonprofit and for-
profit organizations. SSA intended to establish as many projects as 
needed to ensure state-wide coverage for all Social Security Disability 
Insurance (SSDI) and Supplemental Security Income (SSI) beneficiaries 
nationally. The projects funded under this cooperative agreement 
program are part of SSA's strategy to increase the number of 
beneficiaries who return to work and achieve self-sufficiency as the 
result of delivering direct services to them. The overall goal of the 
program is to disseminate accurate information concerning work 
incentives programs and issues related to youth programs to 
beneficiaries with disabilities (including transition-to-work aged 
youth), in order to enable them to make informed choices about work.

Collection Activities

    The BPAO project collects identifying information from the project 
sites and benefits specialists. In addition, data are collected from 
the beneficiaries on background, employment, training, benefits, and 
work incentives. We use the information to manage the program, with 
particular emphasis on contract administration, budgeting, and 
training. In addition, SSA uses the information to evaluate the 
efficacy of the program and to ensure that those dollars appropriated 
for BPAO services are being spent on SSA beneficiaries. The project 
data will be valuable to SSA in its analysis of and future planning for 
the SSDI and SSI programs.
    Type of Request: Extension of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                     Number of                    Average burden     Estimated
               Title of collection                    annual       Frequency of    per  response  annual  burden
                                                     responses       response        (minutes)        (hours)
----------------------------------------------------------------------------------------------------------------
Site............................................             147               1             1.8             4.4
Specialist......................................             422               1             1.8            12.6
Beneficiary.....................................          60,000               1             5.3           5,300
                                                 -----------------
    Total.......................................          60,569  ..............  ..............           5,138
----------------------------------------------------------------------------------------------------------------

    Total burden hours for this request: 5,317 hours.
    4. Information Collections conducted by State Disability 
Determination Services (DDS) on Behalf of SSA--20 CFR, Subpart P, 
404.1503a, 404.1512, 404.1513, 404.1514 404.1517, 404.1519; 20 CFR 
Subpart Q, 404.1613, 404.1614, 404.1624; 20 CFR Subpart I, 416.903a, 
416.912, 416.913, 416.914, 416.917, 416.919 and 20 CFR Subpart J, 
416.1013, 416.1024, 416.1014--0960-0555. The State DDS's collect 
certain information to administer SSA's disability program. The 
information collected is as follows: (1) Medial 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; and (5) 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.
    Type of Request: Revision of an OMB-approved information 
collection.
    (1) MER (Respondents--Medical Providers and Other Sources)
    Number of Responses: 6,665,907.
    Frequency of Response: Unknown.
    Average Burden Per Response: 15 minutes.
    Estimate Annual Burden: 1,666,477.
    (2) CE Medical Evidence (Respondents--Medical Providers)
    Number of Responses: 1,737,152.
    Frequency of Response: Unknown.
    Average Burden Per Response: 30 minutes.
    Estimated Annual Burden: 868,576 hours.
    (3) CE Forms (Respondents-Claimants)

------------------------------------------------------------------------
                                   Appointment form    Medical  release
------------------------------------------------------------------------
Number of respondents..........  868,576............  1,737,152.
Frequency of response..........  1..................  1.
Average burden per response....  5..................  5.
Estimated annual burden........  72,381 hours.......  144,763 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.

[[Page 5383]]

    (5) Pain Forms (Respondents--Claimants)
    Number of Responses: 1,000,000.
    Frequency of Response: 1.
    Average Burden Per Response: 15 minutes.
    Estimated Annual Burden: 250,000 hours.
    5. International Direct Deposit--31 CFR 210--0960-NEW. SSA uses the 
information collected on the International Direct Deposit (IDD) Form, 
form SSA-1199 (Country), to enroll beneficiaries residing abroad in the 
IDD program. There are currently 39 countries where IDD is now 
available, and SSA plans to expand this service to other countries as 
it becomes available. The SSA-1199 (Country) is named according to the 
country for its intended use, but will always request the same basic 
enrollment information. This form is a variation of the SF-1199 A, 
Direct Deposit Sign-Up Form, which is used to enroll a beneficiary in 
direct deposit to a U.S. financial institution. The respondents are 
beneficiaries living in a foreign country who request Direct Deposit to 
a financial institution in their country of residence.
    Type of Request: New information collection.
    Number of Respondents: 5,000.
    Frequency of Response: 1.
    Average Burden Per Response: 5 minutes.
    Estimated Average Burden: 417 hours.

    Dated: January 28, 2004.
Elizabeth A. Davidson,
Reports Clearance Officer, Social Security Administration.
[FR Doc. 04-2215 Filed 2-3-04; 8:45 am]
BILLING CODE 4191-02-P