# Agency Information Collection Activities: Proposed 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 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. You may submit your comments online through *https://www.reginfo.gov/public/do/PRAMain,* referencing Docket ID Number [SSA-2024-0031].
(SSA) Social Security Administration, OLCA, Attn: Reports Clearance Director, Mail Stop 3253 Altmeyer, 6401 Security Blvd., Baltimore, MD 21235, Fax: 833-410-1631. Email address: *[email protected].* Or you may submit your comments online through *https://www.reginfo.gov/public/do/PRAmain* by clicking on Currently under Review—Open for Public Comments and choosing to click on one of SSA's published items.
Please reference Docket ID Number [SSA-2024-0031] in your submitted response.
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 November 12, 2024. Individuals can obtain copies of the collection instruments by writing to the above email address.
1. Work Activity Report—Employee—20 CFR 404.1520(b), 404.1571-404.1576, 404.1584-404.1593, and 416.971-404.976—0960-0059. Section 223(d) of the Social Security Act (Act) defines the term “disability” as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment which one expects to result in death, or which lasted or is expected to last for a continuous period of not less than 12 months. Social Security Disability (SSDI) and Supplemental Security Income (SSI) applicants or recipients can become entitled to payments based on their inability to engage in SGA because of a physical or mental condition. SSA uses Form SSA-821-BK to obtain work information during the initial claims process; the continuing disability review process; post-adjudicative work issue actions; and for Supplemental Security Income (SSI) claims involving work issues. SSA reviews and evaluates the data to determine if the applicant or recipient meets the disability requirements of the law. The respondents are applicants or recipients of Title II Social Security Disability, and Title XVI SSI applicants.
*Type of Request:* Revision of an OMB-approved information collection.
| Modality of completion | Number of | Frequency | Average | Estimated | Average | Average | Total annual |
| --- | --- | --- | --- | --- | --- | --- | --- |
| SSA-821-BK In Office | 64,330 | 1 | 30 | 32,165 | * $13.30 | ** 24 | *** 770,030 |
| SSA-821-BK Phone | 128,660 | 1 | 30 | 64,330 | * 13.30 | ** 19 | *** 1,397,458 |
| SSA-821-BK Returned Via Mail | 192,990 | 1 | 40 | 128,660 | * 13.30 | | *** 1,710,380 |
| SSA-821-BK Electronic | 25,320 | 1 | 45 | 18,990 | * 13.30 | | *** 252,567 |
| Totals | 411,300 | | | 244,145 | | | *** 4,130,435 |
2. Claimant's Medication—20 CFR 404.1512, 416.912—0960-0289. To receive Old Age Survivors and Disability Insurance (OASDI) and SSI payments, the relevant State Disability Determination Service (DDS) or field office (FO) must first adjudicate claimants' applications. If the DDS or FO denies an initial application, the claimants may request for reconsideration of the initial denial. At that time, the claimants may submit addition documentation to further justify their claims. If the DDS denies the claim at the reconsideration level, the claimant may then request a hearing before a judge. Before the hearing, SSA allows the claimant to submit additional evidence to support their claim. In addition, since judges must obtain information from the claimant to update and complete their medical record and to verify the accuracy of the information, SSA also sends the claimant Form HA-4632, Claimant's Medications, to request information from the claimant regarding the current medications they use. This information helps the judge overseeing the case to fully investigate: (1) the claimant's medical treatment and (2) the effects of the medications on the claimant's medical impairments and functional capacity. The judge makes the completed form a part of the documentary evidence of record, placing it in the official record of the proceedings as an exhibit. The respondents are applicants (or their representatives) for OASDI or SSI payments who request a hearing to contest an agency denial of their claim.
*Type of Request:* Revision of an OMB-approved information collection.
| Modality of completion | Number of | Frequency | Average | Estimated | Average | Average | Total annual |
| --- | --- | --- | --- | --- | --- | --- | --- |
| HA-4632—PDF/paper version | 51,000 | 1 | 20 | 17,000 | * $13.30 | ** 21 | *** $463,505 |
| Electronic Records Express Submissions | 249,000 | 1 | 20 | 83,000 | * 31.48 | | *** 2,612,840 |
| Totals | 300,000 | | | 100,000 | | | *** 3,076,345 |
3. Questionnaire for Children Claiming SSI Benefits—20 CFR 416.912(a)—0960-0499. Sections 1614 and 1631 of the Act allows SSA to determine the eligibility of an applicant's claim for SSI payments. Parents or legal guardians seeking to obtain or retain SSI eligibility for their children use Form SSA-3881-BK to provide SSA with the addresses of non-medical sources such as schools, counselors, agencies, organizations, or therapists who would have information about a child's functioning. SSA uses this information to help determine a child's claim or continuing eligibility for SSI. The respondents are the parents, guardians, or other caretakers of: (1) applicants who appeal SSI childhood disability decisions; or (2) recipients undergoing a continuing disability review.
*Type of Request:* Revision of an OMB-approved information collection.
| Modality of completion | Number of | Frequency | Average | Estimated | Average | Average | Total annual |
| --- | --- | --- | --- | --- | --- | --- | --- |
| SSA-3881-BK (Paper Version) | 98,307 | 1 | 30 | 49,154 | * $31.48 | ** 24 | *** $2,785,256 |
| SSA-3881-BK (Intranet Version) | 52,936 | 1 | 30 | 26,468 | * 31.48 | ** 21 | *** 1,416,474 |
| Totals | 151,243 | | | 75,622 | | | *** 4,201,730 |
4. Requests for Self-Employment Information, Employee Information, and Employer Information—20 CFR 422.120—0960-0508. When SSA cannot identify Form W-2 wage data for an individual, we place the data in an earnings suspense file and contact the individual (and certain instances the employer) to obtain the correct information. If the respondent furnishes the name and Social Security Number (SSN) information that agrees with SSA's records, or provides information that resolves the discrepancy, SSA adds the reported earnings to the respondent's Social Security record. We use Forms SSA-L2765, SSA-L3365, and SSA-L4002 for this purpose. The respondents are self-employed individuals and employees whose name and SSN information do not agree with their employer's and SSA's records.
*Type of Request:* Revision of an OMB approved information collection.
| Modality of completion | Number of | Frequency | Average | Estimated | Average | | Total annual |
| --- | --- | --- | --- | --- | --- | --- | --- |
| SSA-L2765 * | 1 | 1 | 10 | 1 | ** $31.48 | | *** $31.48 |
| SSA-L3365 * | 1 | 1 | 10 | 1 | ** 31.48 | | *** 31.48 |
| SSA-L4002 * | 1 | 1 | 10 | 1 | ** 31.48 | | *** 31.48 |
| Totals | 1 | | | 3 | | | *** 94 |
5. Function Report—Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday)—20 CFR 416.912 and 416.924a(a)(2)—0960-0542. As part of SSA's disability determination process, we use Forms SSA-3375-BK through SSA-3379-BK to request information from a child's parent or guardian for children applying for SSI. The five different versions of the form contain questions about the child's day-to-day functioning appropriate to a particular age group; thus, respondents use only one version of the form for each child. The adjudicative team (disability examiners and medical or psychological consultants) of State disability determination services offices collect the information on the appropriate version of this form (in conjunction with medical and other evidence) to form a complete picture of the children's ability to function and their impairment-related limitations. The adjudicative team uses the completed profile to determine: (1) if each child's impairment(s) results in marked and severe functional limitations; and (2) whether each child is disabled. The respondents are parents and guardians of child applicants for SSI.
*Type of Request:* Revision of an OMB-approved information collection.
| Modality of completion | Number of | Frequency | Average | Estimated | Average | Average | Total annual |
| --- | --- | --- | --- | --- | --- | --- | --- |
| SSA-3375 | 26,864 | 1 | 20 | 8,955 | * $31.48 | ** 21 | *** $577,878 |
| SSA-3376 | 53,347 | 1 | 20 | 17,782 | * 31.48 | ** 21 | *** 1,147,540 |
| SSA-3377 | 108,745 | 1 | 20 | 36,248 | * 31.48 | ** 21 | *** 2,339,247 |
| SSA-3378 | 193,800 | 1 | 20 | 64,600 | * 31.48 | ** 21 | *** 4,168,896 |
| SSA-3379 | 142,006 | 1 | 20 | 47,335 | * 31.48 | ** 21 | *** 3,054,725 |
| Totals | 524,762 | | | 174,921 | | | *** 11,288,286 |
6. Representative Payee Report of Benefits and Dedicated Account—20 CFR 416.546, 416.635, 416.640, and 416.665—0960-0576. SSA requires representative payees (RPs) to manage the dedicated account in accordance with our rules, including using the funds for permitted expenditures and reporting on the use of funds. When the SSI recipient requires a dedicated account, SSA notifies the RP to inform them of the need to open the dedicated account and of the rules for managing a dedicated account, including the required submission of a written report accounting for the use of money paid to Social Security or Supplemental Security Income (SSI) recipients into the dedicated account. SSA allows the respondent to submit their own written report, or use Form SSA-6233, which simplifies the process for the respondents. SSA uses Form SSA-6233 to: (1) ensure the RPs use the payments for the recipient's current maintenance and personal needs and properly conserves the remainder; and (2) confirm the funds paid into the dedicated account are spent and saved in compliance with the law. Respondents are RPs for SSI and Social Security recipients.
*Type of Request:* Revision of an OMB-approved information collection.
| Modality of completion | Number of | Frequency | Average | Estimated | Average | Average | Total annual |
| --- | --- | --- | --- | --- | --- | --- | --- |
| SSA-6233 | 68,000 | 1 | 20 | 22,667 | * $31.48 | ** 21 | *** $1,462,781 |
7. Sheltered Workshop Wage Reporting—0960-0771. Sheltered workshops are private non-profit organizations or institutions that implement a recognized program of rehabilitation for handicapped workers or provide such workers with remunerative employment or other occupational rehabilitating activity of an educational or therapeutic nature. Sheltered workshops perform a service for their clients by reporting monthly wages directly to SSA. SSA uses the information these workshops provide to verify and post monthly wages to SSI recipient's records. Most workshops report monthly wage totals to their local SSA office, so we can adjust the client's SSI payment amount in a timely manner and prevent overpayments. Sheltered workshops are motivated to report wages voluntarily as a service to their clients. Respondents are sheltered workshops that report monthly wages for services performed in the workshop.
*Type of Request:* Revision of an OMB-approved information collection.
| Modality of completion | Number of | Frequency | Total | Average | Estimated | Average | Average | Total annual |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Sheltered Workshop Wage Reporting | 244 | 12 | 2,928 | 15 | 732 | * $23.28 | ** 24 | *** $19,322 |
Dated: September 9, 2024.
Naomi Sipple,
Reports Clearance Officer, Social Security Administration.