The Ticket to Work and Self-Sufficiency Program, 20 CFR 411

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-1370 Ticket to Work Individual Work Plan	Form and Instruction	Modified	Available
Form SSA-1392 Employment Network Payment Status Report Request Form	Form and Instruction	New	Available
Form SSA-1401 Employment Network Split Payment Request Form	Form	New	Available
Form SSA-1394 Employment Network Contract Change Form	Form and Instruction	New	Available
Form SSA-1365 State Agency Ticket Assignment Form Ticket to Work and Self-Sufficiency Program	Form	Modified	Available
Form SSA-1398 Self-Employment Income (SEI) Form Beneficiary Quarterly Report Self-Employment	Form and Instruction	Modified	Available
Form SSA-1396 Earnings Inquiry Request Form	Form and Instruction	Modified	Available
Form SSA-1399 Auto Pay Request Form	Form and Instruction	Modified	Available
Form SSA-1393 Employment Network Supplemental Earnings Statement	Form and Instruction	Modified	Available
Form SSA-1389 EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request)	Form and Instruction	Modified	Available
Form SSA-1391 Employment Network Payment Request Form	Form and Instruction	Modified	Available
Electronic Data Exchange Response for Progress Reports (Draft Version)	Form	Removed	Available
Form SSA-1375 Ticket to Work Progress Review Form	Form	Removed	Available
Form SSA-1375 Ticket to Work Progress Review Form	Form	Modified	Available
Addendum - 0644.doc	Supplementary Document	Uploaded 2009-12-01	Available
Supporting Statement - 0644.doc	Supporting Statement A	Uploaded 2009-12-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9680	a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370	Form and Instruction	Modified	Ticket to Work Individual Work Plan
191126	f) 20 CFR 411.575; SSA-1392 - EN Payment Status Report Request	Form and Instruction	New	Employment Network Payment Status Report Request Form
190323	f) 20 CFR 411.560, SSA-1401 - Split Payment Situations	Form	New	Employment Network Split Payment Request Form
190204	i) 20 CFR 411.320; SSA-1394 - EN Contract Changes	Form and Instruction	New	Employment Network Contract Change Form
184502	a) 411.140(d)(3); 411.325(a); 411.150(b)(3) - SSA-1365	Form	Modified	State Agency Ticket Assignment Form Ticket to Work and Self-Sufficiency Program
184464	h) 20 CFR 411.435, 411.615, 411.625 -- Dispute Resolutions		Modified
184463	g) 20 CFR 411.325(f) - Periodic Outcomes Reporting		Modified
184462	f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction	Modified	Self-Employment Income (SEI) Form Beneficiary Quarterly Report Self-Employment
184462	f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction	Modified	Earnings Inquiry Request Form
184462	f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction	Modified	Auto Pay Request Form
184462	f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction	Modified	Employment Network Supplemental Earnings Statement
184462	f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction	Modified	EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request)
184462	f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction	Modified	Employment Network Payment Request Form
184461	e) 20 CFR 411.325(d), 411.415 - Reporting Referral Agreement		Modified
184460	d) 20 CFR 411.365, 411.505, 411.515 - Selecting a Payment System		Modified
184459	c) 20 CFR 411.210(b) -Ticket-Use Status after Not Making Timely Progress		Modified
184458	20 CFR 411.200(b)--SSA-1375 Internet Version (State ENs)	Form	Removed	Electronic Data Exchange Response for Progress Reports (Draft Version)
184458	20 CFR 411.200(b)--SSA-1375 Internet Version (State ENs)	Form	Removed	Ticket to Work Progress Review Form
184458	20 CFR 411.200(b)--SSA-1375 Internet Version (State ENs)	Instruction	Removed
184457	c) 20 CFR 411.200(b) - SSA-1375; SSA-L1373; SSA-L1374; SSA-L1377	Form	Modified	Ticket to Work Progress Review Form
184457	c) 20 CFR 411.200(b) - SSA-1375; SSA-L1373; SSA-L1374; SSA-L1377	Instruction	Modified
184456	c) 20 CFR 411.192(b)&(c) - Request to Place Ticket in Inactive Status		Modified
184450	b) 20 CFR 411.535(a)(1)(iii) - VR Case Closures		Modified
184449	b) 20 CFR 411.145 & 411.325 - Requesting Ticket Unassignments		Modified
184447	a) 20 CFR 411.166; 411.170(b) - Elecronic Data Sharing		Modified

ICR Details

OMB Control No: 0960-0644	ICR Reference No: 200907-0960-009
Status: Historical Active	Previous ICR Reference No: 200804-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: The Ticket to Work and Self-Sufficiency Program, 20 CFR 411
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: 04/20/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/21/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2013	36 Months From Approved	04/30/2010
Responses	206,926	0	121,981
Time Burden (Hours)	63,502	0	46,553
Cost Burden (Dollars)	0	0	0

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Abstract: Through its Ticket to Work Program Manager, SSA uses the information collected to operate and manage the Ticket to Work Program. SSA uses the Ticket to Work Program to assign Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) beneficiaries to a service provider, and follows their progress through the various stages of ticket program participation such as progress reviews or changes in ticket status. Most of the collections in this request require service providers to provide information to SSA for such tasks as selecting a payment system or requesting payments for helping the beneficiary achieve certain work goals. Most of the categories of information collected in this request are required for SSA to be in compliance with the Ticket to Work legislation and provide proper oversight of the program. The respondents are SSDI beneficiaries and blind or disabled SSI beneficiaries and their employment networks or State vocational rehabilitation agencies under the Ticket to Work Program.

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Authorizing Statute(s): US Code: 42 USC 405
   US Code: 42 USC 1320b–19
  

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:
	74 FR 45508	09/02/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 67945	12/21/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 16

table that charts list of burden

IC Title	Form No.	Form Name
20 CFR 411.200(b)--SSA-1375 Internet Version (State ENs)	N/A, SSA-1375	Ticket to Work Progress Review Form ,   Electronic Data Exchange Response for Progress Reports (Draft Version)
a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370	SSA-1370	Ticket to Work Individual Work Plan
a) 20 CFR 411.166; 411.170(b) - Elecronic Data Sharing
a) 411.140(d)(3); 411.325(a); 411.150(b)(3) - SSA-1365	SSA-1365	State Agency Ticket Assignment Form Ticket to Work and Self-Sufficiency Program
b) 20 CFR 411.145 & 411.325 - Requesting Ticket Unassignments
b) 20 CFR 411.535(a)(1)(iii) - VR Case Closures
c) 20 CFR 411.192(b)&(c) - Request to Place Ticket in Inactive Status
c) 20 CFR 411.200(b) - SSA-1375; SSA-L1373; SSA-L1374; SSA-L1377	SSA-1375	Ticket to Work Progress Review Form
c) 20 CFR 411.210(b) -Ticket-Use Status after Not Making Timely Progress
d) 20 CFR 411.365, 411.505, 411.515 - Selecting a Payment System
e) 20 CFR 411.325(d), 411.415 - Reporting Referral Agreement
f) 20 CFR 411.560, SSA-1401 - Split Payment Situations	SSA-1401	Employment Network Split Payment Request Form
f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	SSA-1393, SSA-1391, SSA-1389, SSA-1399, SSA-1396, SSA-1398	Employment Network Payment Request Form ,   EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request) ,   Employment Network Supplemental Earnings Statement ,   Auto Pay Request Form ,   Earnings Inquiry Request Form ,   Self-Employment Income (SEI) Form Beneficiary Quarterly Report Self-Employment
f) 20 CFR 411.575; SSA-1392 - EN Payment Status Report Request	SSA-1392	Employment Network Payment Status Report Request Form
g) 20 CFR 411.325(f) - Periodic Outcomes Reporting
h) 20 CFR 411.435, 411.615, 411.625 -- Dispute Resolutions
i) 20 CFR 411.320; SSA-1394 - EN Contract Changes	SSA-1394	Employment Network Contract Change Form

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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	206,926	121,981	0	100,402	-15,457	0
Annual Time Burden (Hours)	63,502	46,553	0	20,440	-3,491	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The annual reporting burden for these information collections has increased due to the addition of new forms SSA-1391, SSA-1394, and SSA-1401; the new letter SSA-L1375; as well as the combination of two ICs (due to lack of funding, SSA did not create an Internet versions of the SSA-1375 as mentioned in the previous ICR. Rather we allow ENs to submit the form either via fax or email). We are also adjusting the burden for both the SSA-1365 and SSA 1370, which increases the public reporting burden.

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Annual Cost to Federal Government: $7,000,000

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)? No

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: 12/21/2009

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