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Agency Information Collection Activities: Proposed Request

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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 (PRA) of 1995, effective October 1, 1995. This notice includes revisions 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 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:

(SSA), Social Security Administration, OLCA, Attn: Reports Clearance Director, 3100 West High Rise, 6401 Security Blvd., Baltimore, MD 21235, Fax: 410-966-2830, Email address:

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 September 2, 2014. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Medical Report on Adult with Allegation of Human Immunodeficiency Virus Infection; Medical Report on Child with Allegation of Human Immunodeficiency Virus Infection—20 CFR 416.933-20 CFR 416.934 —0960-0500. Section 1631(e)(i) of the Social Security Act (Act) authorizes the Commissioner of SSA to gather information necessary to make an immediate determination about an applicant's claim for Supplemental Security Income (SSI) payments; this procedure is the Presumptive Disability (PD). SSA uses Forms SSA-4814-F5 and SSA-4815-F6 to collect information necessary to determine if an individual with human immunodeficiency virus infection, who is applying for SSI disability payments, meets the requirements for PD. The respondents are the medical sources of the applicants for SSI disability payments.

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

Modality of completionNumber of responsesFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)
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2. SSI Notice of Interim Assistance Reimbursement (IAR)—0960-0546. Section 1631(g) of the Act authorizes SSA to reimburse an IAR agency from an individual's retroactive SSI payment for assistance the IAR agency gave the individual for meeting basic needs while an SSI claim was pending or when SSI payments were suspended or terminated. The State or local agency needs an IAR agreement with SSA to participate in the IAR program. The individual receiving the IAR payment signs an authorization form with an IAR agency to allow SSA to repay the IAR agency for funds paid in advance prior to SSA's determination on the individual's claim. The authorization represents the individual's intent to file for SSI, if they did not file an application prior to SSA receiving the authorization. Agencies who wish to enter into an IAR agreement with SSA need to meet the following requirements:

(a) Reporting Requirements—Each IAR agency agrees to:

(1) Notify SSA of receipt of an authorization for initial claims or cases they are appealing, and submit a copy of that authorization either through a manual or electronic process;

(2) inform SSA of the amount of reimbursement;

(3) submit a written request for dispute resolution on a determination;

(4) notify SSA of interim assistance paid (using the SSA-8125 or the SSA-L8125-F6);

(5) inform SSA of any deceased claimants who participate in the IAR program; and,

(6) review and sign an agreement with SSA.

(b) Recordkeeping Requirements—The IAR agencies agree to retain all notices, agreements, authorizations, and accounting forms for the period defined in the IAR agreement for the purposes of SSA verifying transactions covered under the agreement.

(c) Third Party Disclosure Requirements—Each participating IAR agency agrees to send written notices from the IAR agency to the recipient regarding payment amounts and appeal rights.

(d) Periodic Review of Agency Accounting Process—The IAR agency makes the IAR accounting records of paid cases available for SSA review and verification. SSA conducts reviews either onsite or through the mail of the authorization forms, notices to the claimant, and accounting forms. Upon completion of the review, SSA provides a written report of findings to the IAR agency director. The respondents are State IAR officers.

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

Reporting Requirements

Modality of completionNumber of respondentsFrequency of responseNumber of responsesAverage burden per response (minutes)Estimated total annual burden (hours)
a) State notification of receipt of authorization (Electronic Process)11 StatesOnce per SSI claimant97,33011,622
b) State submission of copy of authorization (Manual Process)27 StatesOnce per SSI claimant68,40533,420
c) State submission of amount of IA paid to recipients (using eIAR)38 StatesOnce per SSI claimant101,352813,514
d) State request for determination—dispute resolutionAverage is about 2 states per yearAs needed2301
e) State computation of reimbursement due form SSA using paper form SSA-L8125-F638 StatesOnce per SSI claimant1,52430762
f) State notification to SSA of deceased claimant20 StatesAs needed when SSI claimant dies while claim is pending401510
g) State reviewing/signing of IAR agreement38 StatesOnce during life of the IAR agreement3812 hours456
h) Maintenance of authorization forms38 StatesOne form per SSI claimant165,735 (includes both denied and approved SSI claims)38,287
i) Maintenance of accounting forms and notices38 StatesOne set per SSI claimant101,35235,068

Third Party Disclosure Requirements

Modality of completionNumber of respondentsFrequency of responseNumber of responsesAverage burden per response (minutes)Estimated total annual burden (hours)
j) Written notice from State to recipient regarding amount of payment38 StatesOnce per SSI claimant101,352711,824
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Periodic Review of Agency Accounting Process

Modality of completionNumber of respondentsFrequency of responseNumber of responsesAverage burden per response (minutes)Estimated total annual burden (hours)
k) Retrieve and consolidate authorization and accounting forms12 StatesOne set of forms per SSI claimant for review by SSA once every 2 to 3 years12336
l) Participate in periodic review12 StatesFor review by SSA once every 2 to 3 years1216192
m) Correct administrative and accounting discrepancies6 StatesTo correct errors discovered by SSA in periodic review6424

Total Administrative Burden

Number of respondentsFrequency of responseNumber of responsesAverage burden per response (minutes)Estimated total annual burden (hours)
Total38 Statesvaries639,161varies45,217

3. 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, SSA may ask the claimant to have a consultative examination, at the agency's expense, if the claimant's medical sources cannot or will not give the agency sufficient evidence to determine whether the claimant is disabled. The medical providers who perform these consultative examinations provide a statement about the claimant's state of disability. Specifically, these medical source statements determine the work-related capabilities of these claimants. SSA collects the medical data on the HA-1151 and HA-1152 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.

Modality of completionNumber of respondentsFrequency of responseAverage burden per response (minutes)Total estimated annual burden (hours)

4. Application for Access to SSA Systems—20 CFR 401.45-0960-0791. SSA uses Form SSA-120, Application for Access to SSA Systems, to allow limited access to SSA's information resources for SSA employees and non-Federal employees (contractors). SSA requires supervisory approval, and local or component Security Officer review prior to granting this access. The respondents are SSA employees and non-Federal Employees (contractors) who require access to SSA systems to perform their jobs.

Note: Because SSA employees are Federal workers exempt from the requirements of the PRA, the burden below is only for SSA contractors.

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

Modality of collectionNumber of respondentsFrequency of responseAverage burden of response (minutes)Estimated total annual burden (hours)
SSA-120 (paper version)2,1481273
SSA-120 (Internet version)1,1051337
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Dated: June 30, 2014.

Faye Lipsky,

Reports Clearance Director, Social Security Administration.

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[FR Doc. 2014-15621 Filed 7-2-14; 8:45 am]