Homeless with Schizophrenia Presumptive Disability (HSPD) Pilot Demonstration

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Presumptive Disability Form	Form	New	Repair queued
Consent Form	Form	New	Repair queued
Supporting Statement - HSPD.docx	Supporting Statement A	Uploaded 2012-01-19	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
199956	Presumptive Disability Form	Form	New
199955	Consent Form	Form	New

ICR Details

OMB Control No:	ICR Reference No: 201109-0960-001
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Homeless with Schizophrenia Presumptive Disability (HSPD) Pilot Demonstration
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted	Conclusion Date: 02/22/2012
	Date Received in OIRA: 01/26/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Federal Strategic Plan to Prevent and End Homelessness 2010 calls on federal agencies to work in partnership with State and local governments, and with the private sector, to end homelessness. A specific objective of the Strategic Plan is to increase economic security by improving access to mainstream programs and services by reducing financial vulnerability to homelessness. The HSPD Pilot Demonstration responds to the Federal Strategic Plan to Prevent and End Homelessness by testing strategies that would remove the barriers that adult applicants with schizophrenia or schizo-affective disorder, and who are homeless, experience completing the Supplemental Security Income (SSI) application process. This will take the form of application assistance and the development of medical evidence by community health and social service providers. We will collect assurances of informed consent from the individual participants on a Consent to Participate form. We also will provide Presumptive Disability payments to homeless applicants. Medical providers will fill out a Presumptive Disability Recommendation form attesting to the type and degree of disability experienced by the applicant. In our evaluation of the interventions, we will use Social Security administrative data to examine whether the interventions improved SSI application outcomes and whether the PD and SSI payments provided improved financial stability to its recipients. In response to and in support of the President's efforts to end homelessness, SSA has developed the Homeless with Schizophrenia Presumptive Disability (HSPD) Pilot Demonstration, which tests both administrative improvements to the SSI application process and interventions that provide financial stability to individuals who are homeless. The pilot is a collaborative effort by the San Francisco Department of Public Health, the City and County of San Francisco Human Services Agency, the Santa Cruz County Health Services Agency, and SSA. The respondents are homeless, adult SSI applicants with schizophrenia or schizo-affective disorder.

---

Authorizing Statute(s): US Code: 42 USC 1310 Name of Law: The Social Security Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 68805	11/07/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 2114	01/13/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Consent Form	N/A	RESEARCH SUBJECT INFORMATION AND CONSENT FORM
Presumptive Disability Form	N/A	Schizophrenia Presumptive Disability Recommendation Form

---

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: This new project increases the public reporting burden. See the chart above for the burden figures.

---

Annual Cost to Federal Government: $0

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

---

Common Form ICR:  No

---

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: 01/26/2012

---