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	Modified	Available
Sample CE Forms	Form and Instruction	Modified	Available
Supporting Statement 0960-0555.docx	Supporting Statement A	Uploaded 2011-07-13	Available
Addendum 0960-0555.doc	Supplementary Document	Uploaded 2011-06-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9480	Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)	Other-Samples of DDS CE Forms	Modified
181780	Category III - Pain/Other Symptoms/Impairment Information	Form	Modified	Pain Questionnaire
179046	Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms")	Form and Instruction	Modified	Sample CE Forms
179022	Category II - MER, ERE & Connect Direct transmission of MER forms (subset of "MER Samples" category)	Other-ERE Transmission of "MER Samples" Category	Modified
179021	Connect Direct Transmission of MER Information (subset of "MER Samples" category)	Other-Sample MER Information (same as previous IC, submitted thr	Removed
179020	Category II - MER Paper Submissions (subset of "MER Samples") category	Other-Sample of MER forms	Modified
179019	Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)	Other-Sample of state DDS Claimant Report Letter/Form	Modified
179018	Category I, CE b) Claimant/Appointment Letter Information (subset of "CE Forms Samples" category)	Other-Sample of Appointment Letter Included	Modified
179017	Category I, CE a) 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	Modified

ICR Details

OMB Control No: 0960-0555	ICR Reference No: 201103-0960-011
Status: Historical Active	Previous ICR Reference No: 200708-0960-016
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: 09/30/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/28/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	36 Months From Approved	09/30/2011
Responses	16,103,000	0	7,553,000
Time Burden (Hours)	2,859,083	0	1,803,560
Cost Burden (Dollars)	0	0	0

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Abstract: State disability determinations services collect the information SSA needs to administer its disability program. For the purposes of this ICR, we divide this information into three categories: 1) consultative examination (a/b/c); 2) medical evidence of record; and 3) pain/other symptoms/impairment. Respondents are individuals, private sector, and State and local governments.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 1382c Name of Law: Social Security Act
   US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 42 USC 421 Name of Law: Social Security Act
  

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:
	76 FR 16849	03/25/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 41320	07/13/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Category I , CE a) Medical Evidence from CE Providers (Paper Forms; subset of "CE Forms Samples" category)
Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms")	N/A	Sample CE Forms
Category I, CE a) Medical Evidence from CE Providers (Electronic Transmission through ERE; subset of "CE Forms Samples" category)
Category I, CE b) Claimant/Appointment Letter Information (subset of "CE Forms Samples" category)
Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)
Category II - MER Paper Submissions (subset of "MER Samples") category
Category II - MER, ERE & Connect Direct transmission of MER forms (subset of "MER Samples" category)
Category III - Pain/Other Symptoms/Impairment Information	Pain Questionnaire	Pain Questionnaire
Connect Direct Transmission of MER Information (subset of "MER Samples" category)

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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	16,103,000	7,553,000	0	-218,400	8,768,400	0
Annual Time Burden (Hours)	2,859,083	1,803,560	0	153,733	901,790	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: Changing Forms

Short Statement: The burden decreased because we combined the two methods of electronic submissions into one instrument for MER electronic submissions. The burden also decreased under response times for the ICI CE(a)medical evidence electronic submission as a result of respondents becoming more familiar/quicker with electronic submissions. The burden increased under all MER ICIs due to the addition of a treatment source questionnaire as part of the MER ICI, thus increasing the overall respondents' response time.

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Annual Cost to Federal Government: $550,000,000

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 07/28/2011

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