[Federal Register Volume 76, Number 215 (Monday, November 7, 2011)]
[Notices]
[Pages 68805-68808]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-28729]


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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 requiring clearance by the Office of 
Management and Budget (OMB) in compliance with Public Law 104-13, the 
Paperwork Reduction Act of 1995, effective October 1, 1995. This notice 
includes revisions to OMB-approved information collections and one new 
information collection request.
    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 ways to minimize burden 
on respondents, including the use of automated collection techniques or 
other forms of information technology. Mail, email, or fax your 
comments and recommendations on the information collection(s) to the 
OMB Desk Officer and SSA Reports Clearance Officer at the following 
addresses or fax numbers.

(OMB), Office of Management and Budget, Attn: Desk Officer for SSA, 
Fax: (202) 395-6974, Email address: [email protected];
(SSA), Social Security Administration, DCRDP, Attn: Reports Clearance 
Officer, 107 Altmeyer Building, 6401 Security Blvd., Baltimore, MD 
21235, Fax No.: (410) 966-2830, Email address: [email protected].

    I. The information collections below are pending at SSA. SSA will 
submit them to OMB within 60 days from the date of this notice. To be 
sure we consider your comments, we must receive them no later than 
January 6, 2012. Individuals can obtain copies of the collection 
instruments by calling the SSA Reports Clearance Officer at (410) 965-
8783 or by writing to the above email address.
    1. Homeless with Schizophrenia Presumptive Disability Pilot 
Demonstration--45 CFR 46.101(b)(5)--0960-NEW. The Federal Strategic 
Plan to Prevent and End Homelessness 2010 calls on Federal agencies to 
work in partnership with State and local governments and with the 
private sector to end homelessness. A specific objective of the 
Strategic Plan is to increase economic security by improving access to 
mainstream programs and services.
    In response to and in support of the President's efforts to end 
homelessness, SSA has developed the Homeless with Schizophrenia 
Presumptive Disability Pilot Demonstration, which tests both 
administrative improvements to the Supplemental Security Income (SSI) 
application process and interventions that provide financial stability 
to individuals who are homeless. The pilot will test strategies that 
would remove the barriers homeless adult applicants with schizophrenia 
or schizoaffective disorder experience when completing the SSI 
application process.
    SSA uses two key forms to conduct the demonstration: The Research 
Subject Information and Consent Form and the Schizophrenia Presumptive 
Disability Recommendation Form. The consent form provides assurances 
from the participants that they understand the demonstration project 
and voluntarily are consenting to participate in it. The Presumptive 
Disability Recommendation form, filled out by a medical authority, 
provides information on how the applicant meets the disability criteria 
necessary to qualify

[[Page 68806]]

for SSI benefits. SSA uses the information in making a presumptive 
disability determination. Respondents are homeless, adult SSI 
applicants with schizophrenia or schizoaffective disorder.
    Type of Request: Request for a new information collection.

----------------------------------------------------------------------------------------------------------------
                                                                                  Average burden     Estimated
                      Form                           Number of     Frequency of    per response    total annual
                                                    respondents      response        (minutes)    burden (hours)
----------------------------------------------------------------------------------------------------------------
Consent Form....................................             200               1             120             400
Presumptive Disability Recommendation Form......              16              13              10              35
                                                 ---------------------------------------------------------------
    Totals......................................             216  ..............  ..............             435
----------------------------------------------------------------------------------------------------------------

    2. Partnership Questionnaire--20 CFR 404.1080-1082--0960-0025. SSA 
considers partnership income in determining entitlement to Social 
Security benefits. SSA uses information from Form SSA-7104 to determine 
several aspects of eligibility for benefits, including the accuracy of 
reported partnership earnings, the veracity of a retirement, and lag 
earnings. The respondents are applicants for, and recipients of, Title 
II Social Security Old Age, Survivors, and Disability Insurance 
benefits.
    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                  Average burden     Estimated
              Collection instrument                  Number of     Frequency of    per response    total annual
                                                     responses       response        (minutes)    burden (hours)
----------------------------------------------------------------------------------------------------------------
SSA-7104........................................          12,350               1              30           6,175
----------------------------------------------------------------------------------------------------------------

    3. Statement of Funds You Provided to Another and Statement of 
Funds You Received--20 CFR 404.1520(b), 404.1571-.1576, 404.1584-.1593 
and 416.971-.976--0960-0059. SSA uses Form SSA-821-BK to collect 
employment information to determine whether recipients have worked 
after becoming disabled and, if so, whether the work is substantial 
gainful activity. SSA field offices use form SSA-821-BK to obtain work 
information during the initial claims process, the continuing 
disability review process, and for SSI claims involving work issues. 
SSA's processing centers and the Office of Disability and International 
Operations use the form to obtain post-adjudicative work issues from 
recipients. SSA reviews and evaluates the data to determine if the 
applicant or recipient meets the disability requirements of the law. 
The respondents are applicants and recipients of Title II Social 
Security and SSI disability payments.
    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                      Average
                                                     Number of     Frequency of     burden per       Estimated
              Collection instrument                 respondents      response        response      total annual
                                                                                     (minutes)    burden (hours)
----------------------------------------------------------------------------------------------------------------
SSA-821-BK......................................         300,000               1              40         200,000
----------------------------------------------------------------------------------------------------------------

    4. Application for Search of Census Records for Proof of Age--20 
CFR 404.716--0960-0097. When preferred evidence of age is not available 
or the available evidence is not convincing, SSA may request the U.S. 
Department of Commerce, Bureau of the Census, to search its records to 
establish a claimant's date of birth. SSA collects information from 
claimants using the SSA-1535-U3 to provide the Census Bureau with 
sufficient identification information to allow an accurate search of 
census records. Additionally, the Census Bureau uses a completed, 
signed SSA-1535-U3 to bill SSA for the search. The respondents are 
applicants for Social Security benefits who need to establish their 
date of birth as a factor of entitlement.
    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                      Average
                                                     Number of     Frequency of     burden per       Estimated
              Collection instrument                 respondents      response        response      total annual
                                                                                     (minutes)    burden (hours)
----------------------------------------------------------------------------------------------------------------
SSA-1535-U3.....................................          18,030               1              12           3,606
----------------------------------------------------------------------------------------------------------------

    5. Modified Benefit Formula Questionnaire--Foreign Pension--0960-
0561. SSA uses Form SSA-308 to determine exactly how much (if any) of a 
foreign pension may be used to reduce the amount of Title II Social 
Security retirement or disability benefits under the modified benefit 
formula. The respondents are applicants for Title II Social Security 
retirement or disability benefits who receive foreign pensions.
    Type of Request: Revision of an OMB-approved information 
collection.

[[Page 68807]]



----------------------------------------------------------------------------------------------------------------
                                                                                      Average
                                                     Number of     Frequency of     burden per       Estimated
              Collection instrument                  responses       response        response      total annual
                                                                                     (minutes)    burden (hours)
----------------------------------------------------------------------------------------------------------------
SSA-308.........................................          13,452               1              10           2,242
----------------------------------------------------------------------------------------------------------------

    6. Medical Source Statement of Ability To Do Work-Related 
Activities (Physical and Mental)--20 CFR 404.1512-404.1514, 404.912-
404.914, 404.1517, 416.917, 404.1519-404.1520, 416.919-416.920, 
404.946, 416.946, 404-1546--0960-0662. In some instances, when a 
claimant appeals a denied disability claim and the claimant's medical 
sources cannot or will not give the agency sufficient evidence to 
determine whether the claimant is disabled, SSA may ask the claimant to 
have a consultative examination at the agency's expense. The medical 
providers who perform these consultative examinations provide a 
statement on Forms HA-1151 and HA-1152 about the claimant's disability 
and ability to perform work-related activities. SSA uses the 
information to assess the work-related physical and mental capabilities 
of claimants who appeal SSA's previous determination on their issue of 
disability. The respondents are medical sources who provide reports 
based either on existing medical evidence or on consultative 
examinations.
    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                      Average
                                                     Number of     Frequency of     burden per       Estimated
              Collection instrument                 respondents      response        response      total annual
                                                                                     (minutes)    burden (hours)
----------------------------------------------------------------------------------------------------------------
HA-1151.........................................           5,000              24              15          30,000
HA-1152.........................................           5,000              24              15          30,000
                                                 ---------------------------------------------------------------
    Totals......................................          10,000  ..............  ..............          60,000
----------------------------------------------------------------------------------------------------------------

    7. Medicare Subsidy Quality Review Forms--20 CFR 418(b)(5)--0960-
0707. The Medicare Modernization Act of 2003 mandated the creation of 
the Medicare Part D prescription drug coverage program and provides 
certain subsidies for eligible Medicare beneficiaries to help pay for 
the cost of prescription drugs. As part of its stewardship duties of 
the Medicare Part D subsidy program, SSA must conduct periodic quality 
review checks of the information Medicare beneficiaries report on their 
subsidy applications (Form SSA-1020). SSA uses the Medicare Quality 
Review program to conduct these checks. The respondents are applicants 
for the Medicare Part D subsidy whom SSA chose to undergo a quality 
review.
    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                  Average burden     Estimated
              Form number and name                   Number of     Frequency of    per response    total annual
                                                    respondents      response        (minutes)    burden (hours)
----------------------------------------------------------------------------------------------------------------
SSA-9301 (Medicare Subsidy Quality Review Case             3,500               1              30           1,750
 Analysis Questionnaire)........................
SSA-9302 (Notice of Quality Review                         3,500               1              15             875
 Acknowledgement Form for those with Phones)....
SSA-9303 (Notice of Quality Review                           350               1              15              88
 Acknowledgement Form for those without Phones).
SSA-9304 (Checklist of Required Information;      ..............  ..............  ..............  ..............
 burden accounted for with forms SSA-9302, SSA-
 9303, SSA-9311, SSA-9314)......................
SSA-9308 (Request for Information)..............           7,000               1              15           1,750
SSA-9310 (Request for Documents)................           3,500               1               5             292
SSA-9311 (Notice of Appointment--Denial--                    450               1              15             113
 Reviewer Will Call)............................
SSA-9312 (Notice of Appointment--Denial--Please               50               1              15              13
 Call Reviewer).................................
SSA-9313 (Notice of Quality Review                         2,500               1              15             625
 Acknowledgement Form for those with Phones)....
SSA-9314 (Notice of Quality Review                           500               1              15             125
 Acknowledgement Form for those without Phones).
SSA-8510 (Authorization to the Social Security             3,500               1               5             292
 Administration to Obtain Personal Information).
                                                 ---------------------------------------------------------------
    Totals......................................          24,850  ..............  ..............           5,923
----------------------------------------------------------------------------------------------------------------

    8. Application to Collect a Fee for Payee Services--20 CFR 
416.640(a) and 20 CFR 416.1103(f)--0960-0719. Sections 205(j)(4)(A) and 
(B) and 1631(a)(2) of the Social Security Act (Act) allow SSA to 
authorize certain organizational representative payees to collect a fee 
for providing payee services. Before an organization may collect this 
fee, they complete and submit Form SSA-445. SSA uses the information to 
determine whether to authorize or deny permission to collect fees for 
payee services. The respondents are private sector businesses or State 
and local government offices applying to become fee-for-service 
organizational representative payees.

[[Page 68808]]

    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                  Average burden     Estimated
              Collection instrument                  Number of     Frequency of    per response    total annual
                                                    respondents      response        (minutes)    burden (hours)
----------------------------------------------------------------------------------------------------------------
Private sector business.........................              90               1              10              15
State/local government offices..................              10               1              10               2
                                                 ---------------------------------------------------------------
    Totals......................................             100  ..............  ..............              17
----------------------------------------------------------------------------------------------------------------

    II. SSA submitted the information collection below to OMB for 
clearance. Your comments regarding the information collection would be 
most useful if OMB and SSA receive them within 30 days from the date of 
this publication. To be sure we consider your comments, we must receive 
them no later than December 7, 2011. Individuals can obtain copies of 
the OMB clearance package by calling the SSA Reports Clearance Officer 
at (410) 965-8783 or by writing to the above email address.
    Report on Individual with Mental Impairment--20 CFR 404.1513 & 
416.913--0960-0058. SSA uses Form SSA-824 to obtain medical evidence 
from medical sources who have treated a Social Security disability 
claimant for a mental impairment. SSA uses the information to establish 
whether a claimant filing for disability benefits has a mental 
impairment that meets the statutory definition of disability in 
accordance with the Social Security Act. The respondents are mental 
impairment treatment providers.

    Note: This is a correction notice. SSA published this 
information collection as an extension on August 1, 2011 at 76 FR 
45902. Since we are revising the Privacy Act Statement, this is now 
a revision of an OMB-approved information collection. We are also 
updating the burden data.

    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                  Average burden     Estimated
              Collection instrument                  Number of     Frequency of    per response    total annual
                                                    respondents      response        (minutes)    burden (hours)
----------------------------------------------------------------------------------------------------------------
SSA-824.........................................             500               1              36             300
----------------------------------------------------------------------------------------------------------------


    Dated: November 2, 2011.
Faye Lipsky,
Reports Clearance Officer, Center for Reports Clearance, Social 
Security Administration.
[FR Doc. 2011-28729 Filed 11-4-11; 8:45 am]
BILLING CODE 4191-02-P