Supporting Statement--SSA-104

Supporting Statement for OMB Clearance for SSA-104

Claimant Travel Reimbursement Request

20 CFR 404.999a-d

0960-NEW

A. Justification

1. 20 CFR 404.999a, 404.999b and 404.999c of the Code of Federal Regulations state that claimants have the right to be reimbursed for their travel expenses to and from a consultative examination (CE). In order to be reimbursed for the travel expenses, the claimant must submit an itemized list of what he or she spent to travel round trip to the CE.

2. Form SSA-104, Claimant Travel Reimbursement Request, is sent to the claimant with the consultative examination appointment notice and the SSA‑91, Authorization to Release Medical Report to Physician. If the claimant wants to be reimbursed for their travel related expenses to the CE and/or test, he or she must complete, sign and return the SSA-104 to the Social Security Administration (SSA). SSA will use the information collected to determine the amount of reimbursement. Travel reimbursement payments cannot be made to the claimant without a signed statement of cost. The respondents are applicants for disability claims.

3. Because the collection of this information is initiated by SSA and the volume of respondents is small, no electronic method is used to collect this information. In addition, SSA requires a signed statement from the claimant.

4. While similar information is collected through the state DDS forms approved under OMB Control No. 0960-0555, SSA requires Federal versions of the forms in order to assist the state DDSs with their disability claims workloads. Each State we assist has their own forms and procedures to collect the same information we are asking for on the SSA-104. However, as a federal component, we do not have the authority to use the State's forms. Since we assist many States with their disability workloads, we need standardized federal forms that can be used in any State we assist.

5. This collection does not impact small businesses or other small entities.

6. If this information were not collected, SSA would be unable to process the reimbursement. Also, since these requests are voluntary and dealt with on an as needed basis, the information cannot be collected less frequently. There are no technical or legal obstacles that prevent burden reduction.

7. There are no special circumstances that would cause this information collection to be conducted in a manner that is not consistent with 5 CFR 1320.5.

8. The 60-day advance Federal Register Notice was published on February 14, 2007 at 72 FR 7107, and SSA has received no public comments. The second Notice was published on May 21, 2007, at 72 FR 28540. There have been no outside consultations with members of the public.

9. SSA provides no payment or gifts to the respondents outside of the reimbursement for travel expenses after processing of the information.

10. The information requested is protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.

11. The information collection does not contain any questions of a sensitive nature.

12. SSA estimates that 11,092 respondents will each submit the SSA-104 once annually. We estimate each response will take 10 minutes to read the instructions, gather the facts, and answer the questions. Therefore, the total annual burden to the public will be approximately 1,849 hours. The total burden is reflected as burden hours, and no separate cost burden has been calculated.

13. There is no known cost burden to the respondents.

14. The annual cost to the Federal Government is approximately $17,082. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. This is an information collection in use without an OMB control number that will increase the public reporting burden.

16. The results of the information collection will not be published.

17. OMB has granted SSA an exemption from the requirement that the expiration date for OMB approval be printed on its program forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB approval. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). This exemption was granted so that otherwise useable editions of forms would not be taken out of circulation because the expiration date had been reached. In addition, Government waste has been avoided because stocks of forms will not have to be destroyed and reprinted.

18. SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

Statistical methods are not used for this information collection.

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