Skip to Content


Agency Information Collection Activities: Proposed Request and Comment Request

Document Details

Information about this document as published in the Federal Register.

Published Document

This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format.

Start Preamble

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 SSA Reports Clearance Officer and to the OMB Desk Officer at the following addresses:

(OMB), Attn: Desk Officer for SSA, New Executive Office Building, Room 10230, 725 17th St., NW, Washington, DC 20503; (SSA), Social Security Administration, DCFAM, Attn: Frederick W. Brickenkamp, 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. Your comments should be submitted to SSA within 60 days from the date of this publication. You can obtain a copy of the collection instruments by calling the SSA Reports Clearance Officer at 410-965-4145, or by writing to him at the address listed above.

1. Pre-1957 Military Service Federal Benefit Questionnaire—0960-0120. Form SSA-2512 collects data used in the claims adjudication process to grant gratuitous military wage credits, when applicable, and solicits sufficient information to make a determination of eligibility. The respondents are individuals who are applying for Social Security benefits on the record of a wage earner with pre-1957 military service.

Number of Respondents: 12,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 2,000 hours.

2. Application for a Social Security Card—0960-0066. The information collected on form SS-5 is needed to assign a Social Security Number (SSN) and issue a card. SSA screens its records to make sure applicants for original SSN cards don't already have SSNs before assigning an original number. SSA also uses the information from the SS-5 to insure that replacement SSN cards are issued to the correct number holder. Use of SSNs enables SSA to keep an accurate record of each individual's earnings for the payment of benefits and for administrative purposes as an identifier for health-maintenance and income-maintenance programs, such as the Retirement, Survivors and Disability Insurance programs, the SSI program and other programs administered by the Federal government including Black Lung, Medicare and veterans compensation and pension programs. The Internal Revenue Service uses the SSN as a taxpayer identification number for those individuals who are eligible to be assigned an SSN. The respondents are applicants for original, duplicate or corrected Social Security cards.

Number of Respondents: 17.6 million.

Frequency of Response: 1.

Average Burden Per Response: 81/2-9 minutes.

Estimated Annual Burden: 2,501,667 hours.

3. Certificate of Responsibility for Welfare and Care of Child Not in Applicant's Custody—0960-0019. SSA uses the information collected on form SSA-781 to decide if “in care” requirements are met by non-custodial parent(s), who is filing for benefits based on having a child in care. The respondents are non-custodial wage earners whose entitlement to benefits depends upon having an entitled child in care.

Number of Respondents: 14,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 2,333 hours.

4. Questionnaire for Children Claiming SSI Benefits—0960-0499. The information collected on form SSA-3881 is used by SSA to evaluate disability in children who apply for Start Printed Page 82443Supplemental Security Income (SSI) payments. The respondents are individuals who apply for SSI benefits for a disabled child.

Number of Respondents: 272,000.

Frequency of Response: 1.

Average Burden Per Response: 30 minutes.

Estimated Annual Burden: 136,000 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 on (410) 965-4145, or by writing to him at the address listed above.

1. Child Relationship Statement—0960-0116. SSA uses the information collected on Form SSA-2519 to help determine the entitlement of children to Social Security benefits under section 216(h)(3) of the Social Security Act (deemed child provision). The respondents are persons providing information about the relationship between the worker and his/her alleged biological child, in connection with the child's application for benefits.

Number of Respondents: 50,000.

Frequency of Response: 1.

Average Burden Per Response: 15 minutes.

Estimated Annual Burden: 12,500 hours.

2. Request to Resolve Questionable Quarters of Coverage (QC); Request for QC History Based on Relationship—0960-0575. Form SSA-512 is used by the States to request clarification from SSA on questionable QCs information. The Personal Responsibility and Work Opportunity Reconciliation Act states that aliens admitted for lawful residence who have worked and earned 40 qualifying QCs for Social Security purposes can generally receive State benefits. Form SSA-513 is used by States to request QC information for an alien's spouse or child in cases where the alien does not sign a consent form giving permission to access his/her Social Security records. QCs can also be allocated to a spouse and/or to a child under age 18, if needed, to obtain 40 qualifying QCs for the alien. The respondents are State agencies that require QC information in order to determine eligibility for benefits.

Number of Respondents200,000350,000
Frequency of Response11
Average Burden Per Response (minute)22
Estimated Annual Burden (hours)6,66711,667

3. Affective Disorder Treatment Demonstration Project—0960-NEW


There is substantial research evidence that affective disorders (i.e., mental disorders that affect a person's mood, such as depression and bipolar disorder) usually respond to treatment; there is also evidence that many individuals with affective disorders do not receive effective treatment. The cost of care is one of the reasons for the low treatment rates of individuals with affective disorder. This may be true for many beneficiaries, particularly those in the Medicare waiting period. Therefore, SSA will test the hypothesis that providing access to treatment will result in improved health status of Disability Insurance (DI) beneficiaries with affective disorders, which might, in turn, lead to increased labor force participation and self-sufficiency. This outcome would benefit both participants and taxpayers.

The Demonstration Project

SSA plans to implement a 5-year demonstration project that will test the effectiveness of providing better access to quality affective disorders treatments for DI beneficiaries who have an affective disorder as their primary reason for disability. Several forms and survey instruments will be used during the demonstration to collect information for screening program participants, beneficiary protection, and program evaluation. Some of the data will be collected from beneficiaries, and other data will be collected from the medical service providers who treat beneficiaries during the study.

The respondents to this collection will be randomly selected DI beneficiaries with an affective disorder and their health care providers.

Annual number of respondentsFrequency of responseAverage burden per responseEstimated annual burden
Beneficiary telephone screening1,068116285
Authorization for release of medical information8551571
Baseline survey400135233
8-Month follow-up survey380132203
16-Month follow-up survey361132193
24-Month follow-up survey343132183
32-Month follow-up survey326135190
Health Provider:
Copy medical records667120222
Medical records questionnaire667110111
Treatment participation screen20011550
Provider credentialing questionnaire15011538
Initial treatment plan15013075
Quarterly progress report143830572
Total Respondents5,708
Total Annual Burden Hrs2,426
Start Signature
Start Printed Page 82444

Dated: December 21, 2000.

Elizabeth A. Davidson,

Acting Reports Clearance Officer, Social Security Administration.

End Signature End Preamble

[FR Doc. 00-33109 Filed 12-27-00; 8:45 am]