Work Activity Questionnaire
Justification
Introduction/Authoring Law and Regulations - Under the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) programs, claimants qualify for payments when a verified physical or mental impairment prevents them from working. When an SSDI beneficiary or SSI recipient returns to work after the onset of the disability, the Social Security Administration (SSA) must evaluate the work effort to determine if the disability claimant still qualifies for payments. If disability beneficiaries and SSI recipients attempt to return to work after receiving disability payments but are unable to continue working, we may request their employers to submit Form SSA-3033-BK, the Employee Work Activity Questionnaire, so that we can evaluate the work attempt. We also use this form to evaluate unsuccessful work and subsidies. SSA is authorized to collect this information according to sections 221, 223(d)(4), 1612(b)(4)(B), and 1614(a)(3)(D) of the Social Security Act; and section 20 CFR 404.1574(a)(1)-(3) of the Code of Federal Regulations.
Description of Collection – SSA uses the information from Form SSA-3033-BK to evaluate a disability beneficiary’s unsuccessful work attempt, including subsidized work attempts. Ultimately, the agency uses the information to determine if a beneficiary may continue to receive disability payments, or if a claimant is eligible for SSDI or SSI payments.
This collection is voluntary for respondents (employers of SSDI or SSI recipients). We conduct this information collection (IC) on an as needed basis, collecting the information on the SSA-3033-BK paper form. SSDI and SSI recipients may make multiple attempts to return to work. Respondents generally complete the form themselves, and do not need assistance from someone else to complete it. SSA employees collect this information.
Use of Information Technology to Collect the Information - This IC is paper only. SSA did not create an electronic version of the form under the agency’s Government Paperwork Reduction Elimination Act (GPEA) plan due to the low number of respondents (15,000), which is less than the GPEA cut-off of 50,000. This form is available as a print-only PDF on SSA’s website.
Why We Cannot Use Duplicate Information - The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents - This collection does not significantly affect small businesses or other small entities. We have minimized the burden to respondents by using check boxes and fill-ins for their responses on the form.
6. Consequence of Not Collecting Information or Collecting it Less Frequently -
If we did not conduct this information collection, we would have no means of evaluating ceased or subsidized work attempts for SSDI and SSI recipients, which could result in lost payments. Since we collect the information only when we are evaluating recipients work activity, we cannot collect it less frequently.
There are no technical or legal obstacles to burden reduction.
7. Special Circumstances - There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public -
SSA published the advance 60-day Federal Register Notice on January 3, 2011, at 76 FR 205, and we did not receive any public comments. We published the 30-day Federal Register Notice on March 25, 2011, at 76 FR 16849. If we receive any comments in response to the 30-day Notice, we will forward them to OMB.
Payment or Gifts to Respondents - SSA does not provide payments or gifts to the respondents.
Assurances of Confidentiality - SSA protects and holds confidential the information it collects 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.
Justification for Sensitive Questions - This IC does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden - Approximately 15,000 private-sector businesses take 15 minutes each to complete Form SSA-3033 annually. The total burden is 3,750 hours, and we did not calculate a separate burden cost.
13. Annual Cost to the Respondents (Other) – This collection does not impose a known cost burden on the respondents.
Annual Cost To Federal Government - The annual cost to the Federal Government for this collection is approximately $46,200. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
15. Program Changes or Adjustments to the Information Collection Request -There are no changes to the public reporting burden.
16. Plans for Publication Information Collection Results - SSA will not publish the results of the information collection.
17. Displaying the OMB Approval Expiration Date - OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so we would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
Exceptions to Certification Statement - 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
SSA does not use statistical methods for this information collection.
| File Type | application/msword |
| File Title | Title of Information Collection and Form Number(s) |
| Author | Naomi |
| Last Modified By | 889123 |
| File Modified | 2011-03-28 |
| File Created | 2010-12-22 |