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Agency Information Collection Activities: Proposed Request and Comment 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 of 1995, effective October 1, 1995. This notice includes a new information collection and 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:

Or you may submit your comments online through, Start Printed Page 10624referencing Docket ID Number [SSA-2017-0003].

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 April 17, 2017. Individuals can obtain copies of the collection instruments by writing to the above email address.

1. Supported Employment Demonstration (SED) Project—0960-NEW. Sponsored by SSA, the SED project builds on the success of the intervention designed for the Mental Health Treatment Study (MHTS) previously funded by SSA. The MHTS provides integrated mental health and vocational services to disability beneficiaries with mental illness. The SED will offer these same services to individuals with mental illness for whom SSA denied Social Security disability benefits. SSA seeks to determine whether offering this evidence-based package of integrated vocational and mental health services to denied disability applicants fosters employment that leads to self-sufficiency; improved mental health and quality of life; and reduced demand for disability benefits. The SED will use a randomized controlled trial to compare the outcomes of two treatment groups and a control group. Study participation spans 36 months beginning on the day following the date of randomization to one of the three study groups. The SED study population consists of individuals aged 18 to 50 who apply for disability benefits alleging a mental illness, and the initial decision is a denial of benefits in the past 60 days. The SED will enroll up to 1,000 participants in each of the three study arms for a total of 3,000 participants: 40 participants in each of three study arms for the 20 urban sites equaling an n of 2,400 urban site participants, and 20 participants in each of three arms for the 10 rural sites equaling an n of 600 rural site participants.

We randomly select and assign each enrolled participant to one of three study arms:

  • Full-Service Treatment (n = 1,000). The multi-component service model from the MHTS comprises the Full-Service Treatment. At its core, it includes an Individual Placement and Support (IPS) supported employment specialist and behavioral health specialist providing IPS supported employment services integrated with behavioral health care. Participants in the full-service treatment group will also receive the services of a Nurse Care Coordinator who coordinates Systematic Medication Management services, as well assistance with: Out-of-pocket expenses associated with prescription behavioral health medications; work-related expenses; and services and treatment not covered by the participant's health insurance.
  • Basic-Service Treatment (n = 1,000). The Basic-Service Treatment model leaves intact IPS supported employment integrated with behavioral health services as the centerpiece of the intervention arm. The Basic-Service Treatment is essentially the Full-Service model without the services of the Nurse Care Coordinator; Systematic Medication Management; and the funds associated with out-of-pocket expenses for prescription behavioral health medications.
  • Usual Services (n = 1,000). This study arm represents a control group against which we can compare the two treatment groups. Participants assigned to this group seek services as they normally would (or would not) in their community. However, at the time of randomization, each Usual Service participant will receive a comprehensive manual describing mental health and vocational services in their locale, along with state and national resources.

This study will test the two treatment conditions against each other and against the control group on multiple outcomes of policy interest to SSA. The key outcomes of interest include: (1) Employment; (2) earnings; (3) income; (4) mental status; (5) quality of life; (6) health services utilization; and (7) SSA disability benefit receipt and amount. SSA is also interested in the study take up rate (participation); knowing who enrolls (and who does not); and fidelity to evidence-based treatments; among other aspects of implementation. Data collection for the evaluation of the SED will consist of the following activities: Baseline in-person participant interviews; quarterly participant telephone interviews; receipt of SSA administrative record data; and collection of site-level program data. Evaluation team members will also conduct site visits involving: (1) Pre-visit environmental scans to understand the local context in which we embed SED services; (2) independent fidelity assessments in conjunction with those carried out by state Mental Health or Vocational Rehabilitation staff; (3) key informant interviews with the IPS specialist, the nurse care coordinator, the case manager, and facility director; (4) focus groups with participants in the Full-Service and Basic-Service Treatment groups; and (5) ethnographic data collection consisting of observations in the natural environment, and person-centered interviews with participants and non-participants. The respondents are study participants and non-participants; family members; IPS specialists; nurse care coordinators; case managers; and facility directors.

Type of Request: Request for a new information collection.

Modality of completionNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)
Competency and CIDI Screener3,0001402,000
Baseline Interview3,0001452,250
Quarterly Interview (Quarters 1, 2, 3, 5, 6, 7, 9, 10, and 11)3,0009209,000
Annual Interview (Quarters 4, 8, and 11)3,0003304,500
Fidelity Assessment Participant Interview180460720
Fidelity Assessment Family Member Interview90460360
Key Informant Interview120460480
Participant Focus Groups6002601,200
Person-Centered Interview180460720
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2. Student Reporting Form—20 CFR 404.352(b)(2); 404.367; 404.368; 404.415; 404.434; 422.135—0960-0088. To qualify for Social Security Title II student benefits, student beneficiaries must be in full-time attendance status at an educational institution. In addition, SSA requires these beneficiaries to report events that may cause a reduction, termination, or suspension of their benefits. SSA collects this information on Forms SSA-1383 and SSA-1383-FC to determine if the changes or events the student beneficiaries report will affect their continuing entitlement to SSA benefits. SSA also uses the SSA-1383 and SSA-1383-FC to calculate the correct benefit amounts for student beneficiaries. The respondents are Social Security Title II student beneficiaries.

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

Modality of completionNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)

3. Advanced Notice of Termination of Child's Benefits & Student's Statement Regarding School Attendance—20 CFR 404.350-404.352, 404.367-404.368—0960-0105. SSA collects information on Forms SSA-1372-BK and SSA-1372-BK-FC to determine whether children of an insured worker meet the eligibility requirements for student benefits. The data we collect allows SSA to determine student entitlement and thether to terminate benefits. The respondents are student claimants for Social Security benefits; their respective schools; and in some cases; their representative payees.

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


Type of respondentNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)
State/Local/Tribal Government99,850134,993


Type of respondentNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)
State/Local/Tribal Government1,1981360
Grand Total200,09618,526

4. Request for Review of Hearing Decision/Order—20 CFR 404.967-404.981, 416.1467-416.1481—0960-0277. Claimants have a statutory right under the Social Security Act and current regulations to request review of an administrative law judge's (ALJ) hearing decision or dismissal of a hearing request on Title II and Title XVI claims. Claimants may request Appeals Council review by filing a written request using Form HA-520. SSA uses the information to establish the claimant filed the request for review within the prescribed time and to ensure the claimant completed the requisite steps permitting the Appeals Council review. The Appeals Council uses the information to: (1) Document the claimant's reason(s) for disagreeing with the ALJ's decision or dismissal; (2) determine whether the claimant has additional evidence to submit; and (3) determine whether the claimant has a representative or wants to appoint one. The respondents are claimants requesting review of an ALJ's decision or dismissal of hearing.

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

Modality of completionNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)
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5. Disability Update Report—20 CFR 404.1589-404.1595 and 416.988-416.996—0960-0511. As part of our statutory requirements, SSA periodically uses Form SSA-455, the Disability Update Report, to evaluate current Title II disability beneficiaries' and Title XVI disability payment recipients' continued eligibility for Social Security disability payments. Specifically, SSA uses the form to determine if: (1) There is enough evidence to warrant referring the respondent for a full medical Continuing Disability Review (CDR); (2) the respondent's impairments are still present and indicative of no medical improvement, precluding the need for a CDR; or (3) the respondent has unresolved work-related issues. SSA mails Form SSA-455 to specific disability recipients, whom we select as possibly qualifying for the CDR process. SSA pre-fills the form with data specific to the disability recipient, except for the sections we ask the recipients to complete. When SSA receives the completed form, we scan it into SSA's system. This allows us to gather the information electronically, and enables SSA to process the returned forms through automated decision logic to decide the proper course of action to take. The respondents are recipients of Title II and Title XVI Social Security disability payments.

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

Modality of completionNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)

II. SSA submitted the information collections below to OMB for clearance. Your comments regarding the information collections would be most useful if OMB and SSA receive them 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than March 16, 2017. Individuals can obtain copies of the OMB clearance package by writing to

1. Agreement to Sell Property—20 CFR 416.1240-1245—0960-0127. Individuals or couples who are otherwise eligible for Supplemental Security Income (SSI) payments, but whose resources exceed the allowable limit may receive conditional payments if they agree to dispose of the excess non-liquid resources and make repayments. SSA uses Form SSA-8060-U3 to document this agreement, and to ensure the individuals understand their obligations. Respondents are applicants for and recipients of SSI payments who will be disposing of excess non-liquid resources.

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

Modality of completionNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)

2. Development of Participation in a Vocational Rehabilitation or Similar Program—20 CFR 404.316(c), 404.337(c), 404.352(d), 404.1586(g), 404.1596, 404.1597(a), 404.327, 404.328, 416.1321(d), 416.1331(a)-(b), and 416.1338, 416.1402—0960-0282. State Disability Determination Services (DDS) must determine if Social Security disability payment recipients whose disability ceased and who participate in vocational rehabilitation programs may continue to receive disability payments. To do this, DDSs need information about the recipients; the types of program participation; and the services they receive under the rehabilitation program. SSA uses Form SSA-4290 to collect this information. The respondents are State employment networks; vocational rehabilitation agencies; or other providers of educational or job training services.

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

Modality of completionNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)

3. Appointment of Representative—20 CFR 404.1707, 404.1720, 408.1101, 416.1507, and 416.1520—0960-0527. Individuals claiming rights or benefits under the Social Security Act (Act) must notify SSA in writing when they appoint an individual to represent them in dealing with SSA. SSA collects the information on Form SSA-1696-U4 to verify the appointment of these representatives. The SSA-1696-U4 allows SSA to inform representatives of items that affect the recipient's claim, and allows claimants to give permission to their appointed representatives to designate a person to receive their claims files. Respondents are applicants for, or recipients of, Social Security disability benefits (SSDI) or SSI payments who are notifying SSA they have appointed a person to represent them in their dealings with SSA.

Type of Request: Revision of an OMB-approved information collection.Start Printed Page 10627

Modality of completionNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)

4. Work Activity Report (Self-Employment)—20 CFR 404.1520(b), 20 CFR 404.1571-404.1576, 20 CFR 404.1584-404.1593, and 20 CFR 416.971-416.976—0960-0598. SSA uses Form SSA-820-U4 to determine initial or continuing eligibility for (1) Title II SSDI, or (2) Title XVI SSI payments. Under Titles II and XVI of the Act, recipients receive disability benefits and SSI payments based on their inability to engage in substantial gainful activity (SGA) due to a physical or mental condition. Therefore, when the recipients resume work, they must report their work so SSA can evaluate and determine by law whether they continue to meet the disability requirements. SSA uses Form SSA-820-U4 to obtain information on self-employment activities of Social Security Title II and XVI disability applicants and recipients. We use the data we obtain to evaluate disability claims, and to help us determine if the claimant meets current disability provisions under Titles II and XVI. Since applicants for disability benefits or payments must prove an inability to perform any kind of SGA generally available in the national economy for which we expect them to qualify based on age, education, and work experience, any work an applicant performed until, or subsequent to, the date the disability allegedly began, affects our disability determination. The respondents are applicants and claimants for SSI payments or SSDI benefits.

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

Modality of completionNumber of respondentsFrequency of responseAverage burden per response (minutes)Estimated total annual burden (hours)
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Dated: February 9, 2017.

Naomi R. Sipple,

Reports Clearance Officer, Social Security Administration.

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[FR Doc. 2017-02941 Filed 2-13-17; 8:45 am]