Site Review Questionnaires for Volume and Fee-for-Service Payees and Beneficiary Interview Form

Forms and Documents

Document Name	Status
Form SSA-637--revised Site Review Questionnaires for Volume and Fee-for-Service Payees Form	Modified
Form SSA-639 (revised) Expanded Monitoring Site Review: Beneficiary Interview Form Form	New
Supporting Statement--0633.doc Supporting Statement A	0000-00-00
SSA639.doc Supplementary Document	2003-10-31
SSA-637.pdf Supplementary Document	2005-05-31
Addendum--0633.doc Supplementary Document	2007-02-02

IC Document Collections

IC ID	Document Title	Status
38057	Site Review Questionnaires for Volume and Fee-for-Service Payees Form	Modified
178591	Expanded Monitoring Site Review: Beneficiary Interview Form Form	New

ICR Details

OMB Control No: 0960-0633	ICR Reference No: 200702-0960-001
Status: Historical Active	Previous ICR Reference No: 200509-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Site Review Questionnaires for Volume and Fee-for-Service Payees and Beneficiary Interview Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/06/2007
	Date Received in OIRA: 04/03/2007
Terms of Clearance: OMB approves this collection consistent with the e-mail sent by SSA on 6/5/07. As noted in the supporting statement, SSA also agrees to adjust the burden for form SSA-624 (OMB Control No. 0960-0069) accordingly.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2010	36 Months From Approved	06/30/2007
Responses	9,488	0	7,860
Time Burden (Hours)	4,784	0	2,426
Cost Burden (Dollars)	0	0	0

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Abstract: In situations where a Social Security beneficiary is incompetent or physically unable to take care of his or her own affairs, SSA may make payment of Social Security and Supplemental Income (SSI) benefits to a relative, another person, or an organization when the best interest of the beneficiary will be served. In certain situations SSA conducts a site review in order to ensure that payees are carrying out their responsibilities in accordance with representative payment policies and procedures, and enables SSA to identify poor payee performance, uncover misuse and initiate corrective action. Triennial site reviews are conducted for fee-for-service payees and all volume payees (i.e., organizations serving 100 or more beneficiaries and individuals serving 20 or more beneficiaries). The reviews include a face-to-face meeting with the payee (and appropriate staff), examination/verification of a sample of beneficiary records and supporting documentation, and usually include beneficiary (if competent adult) or custodian (if different from payee) interviews. Forms SSA-637 and SSA-639 are used to record the information collected during these interviews. The respondents are certain representative payees and also competent Social Security beneficiaries.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: null
   US Code: 42 USC 1383 Name of Law: null
   PL: Pub.L. 108 - 203 102(b) Name of Law: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 2081	01/17/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 13851	03/23/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Expanded Monitoring Site Review: Beneficiary Interview Form	SSA-639 (revised)	Expanded Monitoring Site Review Beneficiary Review Form
Site Review Questionnaires for Volume and Fee-for-Service Payees	SSA-637--revised	Expanded Monitoring Site Review Questionnaire for Volume and Fee for Service Payees

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	9,488	7,860	0	1,628	0	0
Annual Time Burden (Hours)	4,784	2,426	0	2,358	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: 15. The number of payees who meet the criteria for site reviews under P.L. 108-203 has increased each year. In addition, we are eliminating form SSA-638 which was used as the interview guide for those payees who qualified as fee for service payees. The revised SSA-637 will now be used to interview these payees instead (see addendum). In addition, SSA also reviews a number of payees randomly. The number of payees chosen for random review is derived from a formula tied to the number of payees subject to site reviews. Previously, the burden hours for random reviews were reported in the burden hours for form SSA-624 (0960-0069). To simplify procedures for our field offices and ensure that payees are interviewed thoroughly, we are replacing the SSA-624 with the SSA-637. The SSA-624 has other uses so while the form is being eliminated for random reviews, it will not become obsolete. The SSA-624 was also used to document the beneficiary interviews conducted with random reviews. Due to the expansion of the SSA-637 in order to incorporate those questions previously asked on the SSA-638 and SSA-624, we have adjusted the time per response to two hours to accommodate the increase in questions which the respondents will answer. The SSA-639 will now be used to conduct the beneficiary interview portion of the random review (see addendum). The burden hours for the SSA-624 will be adjusted accordingly after approval of these changes.

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Annual Cost to Federal Government: $109,016

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/03/2007

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