Certificate of Incapacity

Forms and Documents

Document Name	Status
Form SSA-604 Certificate of Incapacity Form and Instruction	Modified
Addendum for Certificate of Incapacity.doc Supporting Statement B	2009-12-10
Supporting_statement_0739_(revised)[1].doc Supporting Statement A	2009-12-15

IC Document Collections

IC ID	Document Title	Status
44832	Certificate of Incapacity Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0739	ICR Reference No: 200907-0960-014
Status: Historical Active	Previous ICR Reference No: 200608-0960-010
Agency/Subagency: SSA	Agency Tracking No:
Title: Certificate of Incapacity
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: 04/02/2010
	Date Received in OIRA: 12/15/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2013	36 Months From Approved	04/30/2010
Responses	50	0	38
Time Burden (Hours)	38	0	29
Cost Burden (Dollars)	0	0	0

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Abstract: Rules governing the Federal Employee Health Benefits (FEHB) plan state that for federal employees' children ages 22 or over to retain health benefits, they must be incapable of self-support due to a disability that 1) pre-dated the child's 22nd birthday, 2) is serious, and 3) will last at least a year. Form SSA-604, the Certificate of Incapacity, is used by physicians to document and certify such a disability for their patients who are children of federal employees. The respondents are these physicians.

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Authorizing Statute(s): None

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 41959	08/19/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 55080	10/26/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Certificate of Incapacity	SSA-604	Certificate of Incapacity

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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	50	38	0	0	12	0
Annual Time Burden (Hours)	38	29	0	0	9	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: The increase in burden hours is due to more recipients are becoming aware of the benefit extension for children. SSA reviews all applications submitted.

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Annual Cost to Federal Government: $2,789

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: 12/15/2009

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