# 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 extensions 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, (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-2024-0052] in your submitted response.
I. The information collection below is pending at SSA. SSA will submit it 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 February 4, 2025. Individuals can obtain copies of the collection instrument by writing to the above email address.
Coverage of Employees of State and Local Governments—20 CFR 404—0960-0425. The Code of Federal Regulations at 20 CFR 404, Subpart M, prescribes the rules for States submitting reports of deposits and recordkeeping to SSA. SSA requires States (and interstate instrumentalities) to provide wage and deposit contribution information for pre-1987 periods. Not all states have completely satisfied their pending wage report and contribution liability with SSA for pre-1987 tax years. SSA needs these regulations until all pending items with all states are closed out, and to provide for collection of this information in the future, if necessary. The respondents are State and local governments or interstate instrumentalities.
*Type of Request:* Extension of an OMB-approved Information Collection.
| Regulation section | Number of | Frequency of response | Average | Total | Average | Total annual |
| --- | --- | --- | --- | --- | --- | --- |
| 404. 1204 (a) & (b) | 52 | 1 | 30 | 26 | $32.39 | ** $842 |
| 404.1215 | 52 | 1 | 60 | 52 | * 32.39 | ** 1,684 |
| 404. 1216 (a) & (b) | 52 | 1 | 60 | 52 | * 32.39 | ** 1,684 |
| Totals | 156 | | | 130 | | ** 4,210 |
II. SSA submitted the information collections below to OMB for clearance. Your comments regarding these 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 January 6, 2025. Individuals can obtain copies of these OMB clearance packages by writing to the *[email protected].*
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. SSA uses Form SSA-821-BK to collect recipient employment information to determine whether recipients worked after becoming disabled and, if so, whether the work is substantial gainful activity. In addition, SSA uses the SSA-821-BK and SSA-821-APP 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 of | 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 Supplemental Security Income (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 of | Average | Estimated | Average | Average | Total annual |
| --- | --- | --- | --- | --- | --- | --- | --- |
| HA-46321—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 allow 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 nonmedical 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 of | 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. Waiver of Right to Appear—Disability Hearing—20 CFR 404.913-404.914, 404.916(b)(5), 416.1413-416.1414, 416.1416(b)(5)—0960-0534. Claimants for Social Security disability payments or their representatives can use Form SSA-773-U4 to waive their right to appear at a disability hearing. The disability hearing officer uses the signed form as a basis for not holding a hearing, and for preparing a written decision on the claimant's request for disability payments based solely on the evidence of record. The respondents are disability claimants for Social Security benefits or SSI payments, or their representatives, who wish to waive their right to appear at a disability hearing.
*Type of Request:* Revision of an OMB-approved information collection.
| Modality of completion | Number of | Frequency of | Average | Estimated | Average | Average | Total annual |
| --- | --- | --- | --- | --- | --- | --- | --- |
| SSA-773-U4 | 4,356 | 1 | 3 | 218 | * $13.30 | ** 24 | *** $26,068 |
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 of | 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 |
Dated: December 2, 2024.
Naomi Sipple,
Reports Clearance Officer, Social Security Administration.