Agency Information Collection Activities: Proposed Request and Comment Request, 68805-68808 [2011-28729]
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Federal Register / Vol. 76, No. 215 / Monday, November 7, 2011 / Notices
fax your comments and
recommendations on the information
For Physical Damage:
collection(s) to the OMB Desk Officer
Homeowners With Credit Availand SSA Reports Clearance Officer at
able Elsewhere ......................
the following addresses or fax numbers.
Homeowners Without Credit
(OMB), Office of Management and
Available Elsewhere ..............
Budget, Attn: Desk Officer for SSA,
Businesses With Credit AvailFax: (202) 395–6974, Email address:
able Elsewhere ......................
OIRA_Submission@omb.eop.gov;
Businesses
Without
Credit
(SSA), Social Security Administration,
Available Elsewhere ..............
Non-Profit Organizations With
DCRDP, Attn: Reports Clearance
Credit Available Elsewhere ...
Officer, 107 Altmeyer Building, 6401
Non-Profit Organizations WithSecurity Blvd., Baltimore, MD 21235,
out Credit Available ElseFax No.: (410) 966–2830, Email
where .....................................
address: OPLM.RCO@ssa.gov.
For Economic Injury:
I. The information collections below
Businesses and Small Agriculare pending at SSA. SSA will submit
tural Cooperatives Without
Credit Available Elsewhere ...
4.000
them to OMB within 60 days from the
Percent
Non-Profit Organizations Withdate of this notice. To be sure we
out Credit Available Elseconsider your comments, we must
where .....................................
3.000 For Physical Damage:
receive them no later than January 6,
Non-Profit Organizations With
Credit Available Elsewhere ...
3.250 2012. Individuals can obtain copies of
The number assigned to this disaster
the collection instruments by calling the
Non-Profit Organizations Withfor physical damage is 12901C and for
SSA Reports Clearance Officer at (410)
out Credit Available Elseeconomic injury is 129020.
where .....................................
3.000 965–8783 or by writing to the above
The State which received an EIDL
For Economic Injury:
email address.
Declaration # is Florida.
Non-Profit Organizations With1. Homeless with Schizophrenia
out Credit Available Else(Catalog of Federal Domestic Assistance
Presumptive Disability Pilot
where .....................................
3.000 Demonstration—45 CFR 46.101(b)(5)—
Numbers 59002 and 59008)
0960–NEW. The Federal Strategic Plan
Dated: October 27, 2011.
The number assigned to this disaster
to Prevent and End Homelessness 2010
Karen G. Mills,
for physical damage is 129048 and for
calls on Federal agencies to work in
Administrator.
economic injury is 129058.
partnership with State and local
[FR Doc. 2011–28702 Filed 11–4–11; 8:45 am]
(Catalog of Federal Domestic Assistance
governments and with the private sector
BILLING CODE 8025–01–P
Numbers 59002 and 59008)
to end homelessness. A specific
objective of the Strategic Plan is to
James E. Rivera,
increase economic security by
SMALL BUSINESS ADMINISTRATION
Associate Administrator for Disaster
improving access to mainstream
Assistance.
[Disaster Declaration #12904 and #12905]
programs and services.
[FR Doc. 2011–28703 Filed 11–4–11; 8:45 am]
In response to and in support of the
Louisiana Disaster #LA–00043
BILLING CODE 8025–01–P
President’s efforts to end homelessness,
SSA has developed the Homeless with
AGENCY: U.S. Small Business
Schizophrenia Presumptive Disability
Administration.
SOCIAL SECURITY ADMINISTRATION
Pilot Demonstration, which tests both
ACTION: Notice.
administrative improvements to the
Agency Information Collection
SUMMARY: This is a Notice of the
Supplemental Security Income (SSI)
Activities: Proposed Request and
Presidential declaration of a major
application process and interventions
Comment Request
disaster for Public Assistance Only for
that provide financial stability to
the State of Louisiana (FEMA–4041–
The Social Security Administration
individuals who are homeless. The pilot
DR), dated 10/28/2011.
(SSA) publishes a list of information
will test strategies that would remove
Incident: Tropical Storm Lee.
collection packages requiring clearance
the barriers homeless adult applicants
Incident Period: 09/01/2011 through
by the Office of Management and
with schizophrenia or schizoaffective
09/05/2011.
Budget (OMB) in compliance with
disorder experience when completing
Effective Date: 10/28/2011.
Public Law 104–13, the Paperwork
the SSI application process.
Physical Loan Application Deadline
SSA uses two key forms to conduct
Reduction Act of 1995, effective October
Date: 12/27/2011.
the demonstration: The Research
1, 1995. This notice includes revisions
Economic Injury (EIDL) Loan
Subject Information and Consent Form
to OMB-approved information
Application Deadline Date: 07/30/2012. collections and one new information
and the Schizophrenia Presumptive
ADDRESSES: Submit completed loan
Disability Recommendation Form. The
collection request.
applications to: U.S. Small Business
SSA is soliciting comments on the
consent form provides assurances from
Administration, Processing and
accuracy of the agency’s burden
the participants that they understand
Disbursement Center, 14925 Kingsport
estimate; the need for the information;
the demonstration project and
Road, Fort Worth, TX 76155.
its practical utility; ways to enhance its
voluntarily are consenting to participate
quality, utility, and clarity; and ways to
FOR FURTHER INFORMATION CONTACT: A.
in it. The Presumptive Disability
minimize burden on respondents,
Escobar, Office of Disaster Assistance,
Recommendation form, filled out by a
including the use of automated
U.S. Small Business Administration,
medical authority, provides information
collection techniques or other forms of
409 3rd Street SW., Suite 6050,
on how the applicant meets the
information technology. Mail, email, or
Washington, DC 20416.
disability criteria necessary to qualify
Notice is
hereby given that as a result of the
President’s major disaster declaration on
10/28/2011, Private Non-Profit
5.000 organizations that provide essential
services of governmental nature may file
2.500
disaster loan applications at the address
6.000 listed above or other locally announced
locations.
The following areas have been
4.000
determined to be adversely affected by
3.250 the disaster:
Primary Parishes: East Feliciana,
Jefferson, Lafourche, Plaquemines,
3.000
Saint Bernard, Saint Charles,
Terrebonne, West Feliciana.
The Interest Rates are:
Percent
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68805
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SUPPLEMENTARY INFORMATION:
PO 00000
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Federal Register / Vol. 76, No. 215 / Monday, November 7, 2011 / Notices
for SSI benefits. SSA uses the
information in making a presumptive
disability determination. Respondents
are homeless, adult SSI applicants with
schizophrenia or schizoaffective
disorder.
Number of
respondents
Form
Type of Request: Request for a new
information collection.
Average
burden per
response
(minutes)
Frequency of
response
Estimated total
annual burden
(hours)
Consent Form ..................................................................................................
Presumptive Disability Recommendation Form ...............................................
200
16
1
13
120
10
400
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
Number of
responses
Collection instrument
SSA–7104 ........................................................................................................
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
Number of
respondents
SSA–821–BK ...................................................................................................
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
Number of
respondents
mstockstill on DSK4VPTVN1PROD with NOTICES
SSA–1535–U3 .................................................................................................
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
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Sfmt 4703
Average
burden per
response
(minutes)
30
Estimated total
annual burden
(hours)
6,175
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 OMBapproved information collection.
Frequency of
response
1
Average
burden per
response
(minutes)
40
Estimated total
annual burden
(hours)
200,000
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 OMBapproved information collection.
Frequency of
response
18,030
the amount of Title II Social Security
retirement or disability benefits under
the modified benefit formula. The
respondents are applicants for Title II
PO 00000
1
300,000
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
Collection instrument
Frequency of
response
12,350
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
Collection instrument
Age, Survivors, and Disability Insurance
benefits.
Type of Request: Revision of an OMBapproved information collection.
1
Average
burden per
response
(minutes)
12
Estimated total
annual burden
(hours)
3,606
Social Security retirement or disability
benefits who receive foreign pensions.
Type of Request: Revision of an OMBapproved information collection.
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Federal Register / Vol. 76, No. 215 / Monday, November 7, 2011 / Notices
Number of
responses
Collection instrument
SSA–308 ..........................................................................................................
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
13,452
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
Number of
respondents
Collection instrument
Average
burden per
response
(minutes)
Frequency of
response
1
Estimated total
annual burden
(hours)
10
2,242
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 OMBapproved information collection.
Average
burden per
response
(minutes)
Frequency of
response
Estimated total
annual burden
(hours)
HA–1151 ..........................................................................................................
HA–1152 ..........................................................................................................
5,000
5,000
24
24
15
15
30,000
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
Number of
respondents
Form number and name
Totals ........................................................................................................
mstockstill on DSK4VPTVN1PROD with NOTICES
SSA–9301 (Medicare Subsidy Quality Review Case Analysis Questionnaire)
SSA–9302 (Notice of Quality Review Acknowledgement Form for those with
Phones) ........................................................................................................
SSA–9303 (Notice of Quality Review 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) ..............................................................
SSA–9310 (Request for Documents) ..............................................................
SSA–9311 (Notice of Appointment—Denial— Reviewer Will Call) .................
SSA–9312 (Notice of Appointment—Denial—Please Call Reviewer) .............
SSA–9313 (Notice of Quality Review Acknowledgement Form for those with
Phones) ........................................................................................................
SSA–9314 (Notice of Quality Review Acknowledgement Form for those
without Phones) ...........................................................................................
SSA–8510 (Authorization to the Social Security Administration to Obtain
Personal Information) ...................................................................................
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
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Average
burden per
response
(minutes)
Frequency of
response
Estimated total
annual burden
(hours)
3,500
1
30
1,750
3,500
1
15
875
350
1
15
88
........................
7,000
3,500
450
50
........................
1
1
1
1
........................
15
5
15
15
........................
1,750
292
113
13
2,500
1
15
625
500
1
15
125
3,500
1
5
292
24,850
........................
........................
5,923
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
PO 00000
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 OMBapproved information collection.
Sfmt 4703
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.
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Federal Register / Vol. 76, No. 215 / Monday, November 7, 2011 / Notices
Type of Request: Revision of an OMBapproved information collection.
Number of
respondents
Collection instrument
Average
burden per
response
(minutes)
Frequency of
response
Estimated total
annual burden
(hours)
Private sector business ...................................................................................
State/local government offices ........................................................................
90
10
1
1
10
10
15
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
Number of
respondents
Collection instrument
SSA–824 ..........................................................................................................
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
DEPARTMENT OF STATE
[Public Notice: 7679]
mstockstill on DSK4VPTVN1PROD with NOTICES
Culturally Significant Objects Imported
for Exhibition
Determinations: ‘‘Transition to
Christianity: Art of Late Antiquity, 3rd–
7th Century AD’’
SUMMARY: Notice is hereby given of the
following determinations: Pursuant to
the authority vested in me by the Act of
October 19, 1965 (79 Stat. 985; 22 U.S.C.
2459), Executive Order 12047 of March
27, 1978, the Foreign Affairs Reform and
Restructuring Act of 1998 (112 Stat.
2681, et seq.; 22 U.S.C. 6501 note, et
seq.), Delegation of Authority No. 234 of
October 1, 1999, Delegation of Authority
No. 236–3 of August 28, 2000 (and, as
appropriate, Delegation of Authority No.
257 of April 15, 2003), I hereby
determine that the objects to be
included in the exhibition ‘‘Transition
to Christianity: Art of Late Antiquity,
3rd–7th Century AD,’’ imported from
VerDate Mar<15>2010
17:50 Nov 04, 2011
Jkt 226001
For
further information, including a list of
the exhibit objects, contact Julie
Simpson, Attorney-Adviser, Office of
the Legal Adviser, U.S. Department of
State (telephone: (202) 632–6467). The
mailing address is U.S. Department of
State, SA–5, L/PD, Fifth Floor (Suite
5H03), Washington, DC 20522–0505.
FOR FURTHER INFORMATION CONTACT:
Dated: October 28, 2011.
J. Adam Ereli,
Principal Deputy Assistant Secretary, Bureau
of Educational and Cultural Affairs,
Department of State.
[FR Doc. 2011–28805 Filed 11–4–11; 8:45 am]
PO 00000
Frm 00092
Fmt 4703
Sfmt 4703
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 OMBapproved information collection. We are also
updating the burden data.
Type of Request: Revision of an OMBapproved information collection.
Frequency of
response
500
abroad for temporary exhibition within
the United States, are of cultural
significance. The objects are imported
pursuant to loan agreements with the
foreign owners or custodians. I also
determine that the exhibition or display
of the exhibit objects at the Onassis
Cultural Center, New York, NY, from on
or about December 6, 2011, until on or
about May 14, 2012, and at possible
additional exhibitions or venues yet to
be determined, is in the national
interest. I have ordered that Public
Notice of these Determinations be
published in the Federal Register.
BILLING CODE 4710–05–P
accordance with the Social Security Act.
The respondents are mental impairment
treatment providers.
Average
burden per
response
(minutes)
1
36
Estimated total
annual burden
(hours)
300
DEPARTMENT OF STATE
[Public Notice: 7677]
Exchange Visitor Program—Cap on
Current Participant Levels and
Moratorium on New Sponsor
Applications for Summer Work Travel
Program
Department of State.
Notice Regarding the Summer
Work Travel Program.
AGENCY:
ACTION:
Effective January 1, 2012, the
Department is restricting the size of the
Exchange Visitor Program (J–1visa)
category of Summer Work Travel to
2011 actual participant levels. The
Department is also announcing,
effective immediately, a moratorium on
designation of new Summer Work
Travel sponsor organizations.
FOR FURTHER INFORMATION CONTACT: Rick
A. Ruth, Deputy Assistant Secretary,
Acting, Bureau of Educational and
Cultural Affairs, U.S. Department of
State, SA–5, Floor 5, 2200 C Street NW.,
Washington, DC 20522–0505; Tel: (202)
632–2805. Email: JExchanges@state.gov.
SUPPLEMENTARY INFORMATION: The
Summer Work Travel (SWT) program
allows foreign post-secondary students
to come to the United States during
their major academic break for a
SUMMARY:
E:\FR\FM\07NON1.SGM
07NON1
]]>Agencies
[Federal Register Volume 76, Number 215 (Monday, November 7, 2011)]
[Notices]
[Pages 68805-68808]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-28729]
=======================================================================
-----------------------------------------------------------------------
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: OIRA_Submission@omb.eop.gov;
(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: OPLM.RCO@ssa.gov.
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
