Clearance of Information Collections Conducted by State Disability Determination Services on Behalf of SSA

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Pain Questionnaire Pain Questionnaire	Form	New	Available
Sample CE Forms	Form and Instruction	Unchanged	Available
Addendum--0555 (F).doc	Supplementary Document	Uploaded 2008-05-08	Available
0960-0555 supporting statement-2007[1].doc	Supporting Statement A	Uploaded 2008-05-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9480	Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)	Other-Samples of DDS CE Forms	Unchanged
181780	Pain Questionnaire	Form	New	Pain Questionnaire
179046	CE Source Credentialing Information (Subset of "CE Sample Forms")	Form and Instruction	Unchanged	Sample CE Forms
179022	ERE transmission of MER forms (subset of "MER Samples" category)	Other-ERE Transmission of "MER Samples" Category	Unchanged
179021	Connect Direct Transmission of MER Information (subset of "MER Samples" category)	Other-Sample MER Information (same as previous IC, submitted thr	Unchanged
179020	MER Paper Submissions (subset of "MER Samples") category	Other-Sample of MER forms	Unchanged
179019	Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)	Other-Sample of state DDS Claimant Report Letter/Form	Unchanged
179018	CE Claimant/Appointment Letter Information (subset of "CE Forms Samples" category)	Other-Sample of Appointment Letter Included	Unchanged
179017	Medical Evidence from CE Providers (Electronic Transmission through ERE; subset of "CE Forms Samples" category)	Other-Sample of types of information sent through ERE; electroni	Unchanged

ICR Details

OMB Control No: 0960-0555	ICR Reference No: 200708-0960-016
Status: Historical Active	Previous ICR Reference No: 200703-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Clearance of Information Collections Conducted by State Disability Determination Services on Behalf of SSA
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: 08/15/2008
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/30/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2011	36 Months From Approved	05/31/2010
Responses	7,553,000	0	6,553,000
Time Burden (Hours)	1,803,560	0	1,553,560
Cost Burden (Dollars)	0	0	0

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Abstract: The information collections are conducted in support of SSA's disability programs. The consultative exam (CE) report medical evidence of record and pain report are used in the determination of disability. The information collected from potential CE providers is used to verify the providers' credentials and licenses. The information collected from claimants is used to obtain release of medical information and to confirm scheduled CE appointments. The respondents are medical provider and claimants for disability.

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Authorizing Statute(s): US Code: 42 USC 423
   US Code: 42 USC 1382c
   US Code: 42 USC 405
   US Code: 42 USC 1383
   US Code: 42 USC 421
  

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:
	73 FR 1253	01/07/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 21400	04/21/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
CE Claimant/Appointment Letter Information (subset of "CE Forms Samples" category)
CE Source Credentialing Information (Subset of "CE Sample Forms")	N/A	Sample CE Forms
Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)
Connect Direct Transmission of MER Information (subset of "MER Samples" category)
ERE transmission of MER forms (subset of "MER Samples" category)
MER Paper Submissions (subset of "MER Samples") category
Medical Evidence from CE Providers (Electronic Transmission through ERE; subset of "CE Forms Samples" category)
Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)
Pain Questionnaire	Pain Questionnaire	Pain Questionnaire

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ICR Summary of Burden

table that charts list 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	7,553,000	6,553,000	0	1,000,000	0	0
Annual Time Burden (Hours)	1,803,560	1,553,560	0	250,000	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: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The total burden for this collection has been increased by 250,000 hours. This increase is due to the inclusion of pain/symptoms information.

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Annual Cost to Federal Government: $436,000,000

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: 05/30/2008

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