Justification for Non Substantive Changes 0960-0189

Justification for Non-Substantive Changes for

SSA-2930 (RSI/DI Quality Review Case Analysis),

SSA-L8550-U3 (Appointment Letter- Sample Individual),

SSA-L8551-U3 (Appointment Letter- Sample Auxiliaries),

SSA-L8552-U3 (Appointment Letter-Representative Payee),

SSA-L8553-U3 (Beneficiary Telephone Contact),

SSA-L8554-U3 (Representative Payee Telephone Contact)

OMB: 0960-0189

Background

The Social Security Administration (SSA) uses Forms SSA-2930, SSA-2931 and SSA-2932 to establish a national payment accuracy rate for all cases in payment status, and to serve as a source of information regarding problem areas in the Retirement and Survivors Insurance (RSI) and Disability Insurance (DI) programs. We also use the information to measure the accuracy rate for newly adjudicated RSI/DI cases.

All of the information on these forms is collected through interviews with the beneficiaries. We conduct approximately 75 percent of these interviews over the telephone, and conduct 25 percent in face-to-face interviews in a field office. An SSA employee is conducting all interviews, writing respondents’ answers to the questions directly on the paper form.

We send each respondent an appointment letter for the interviews; respondents receive one of the following letters for an appointment: SSA-L8550-U3 (Appointment Letter – Sample Individual), SSA‑L8551‑U3 (Appointment Letter – Sample Family), or the SSA-L8552-U3 (Appointment Letter – Rep Payee); we send respondents a notice for a telephone contact review using either the SSA-L8553-U3 (Beneficiary Telephone Contact) or the SSA-L8554-U3 (Rep Payee Telephone Contact).

Revisions to the Collection Instruments

Change 1: SSA-2930-BK – RSI/DI Quality Review Case Analysis (interview workbook)

Justification

We are requesting to reformat the SSA-2930 (Review Case Analysis – Sampled Number Holder) interview workbook to enhance the overall efficiency and flow of the interview between the interviewer and the respondent. This reformatting coincides with our action to discontinue the Index of Dollar Accuracy Review (review for new awards) portion of the interview as described in the June 8, 2011 OMB-approved information collection request. We are reconfiguring the form to reflect this change. We are not adding or removing questions, nor are we adding or decreasing the burden. We describe specific reformatting changes to the SSA-2930 in detail below.

Change 2: SSA-L8550-U3 (Appointment Letter- Sample Individual), SSA-L8551-U3 (Appointment Letter- Sample Auxiliaries), SSA-L8552-U3 (Appointment Letter-Rep Payee), SSA-L8553-U3 (Beneficiary Telephone Contact), and SSA-L8554-U3 (Rep Payee Telephone Contact) letters.

Justification 2:

In conjunction with the Commissioner of Social Security’s (COSS) clear writing initiative to promote clear and effective communication in our written correspondence with the public, we are revising the letters to reflect the COSS clear writing principles.

Specific reformatting to the SSA-2930 – RSI/DI Quality Review Case Analysis – Sampled Number Holder

Page 1 of _20_

Opening paragraph: NOTE TO REVIEWER – Remove third sentence that begins “Stress that this case…” as highlighted in the text from the form below. (We state this information in the appointment letter.)

NOTE TO REVIEWER: In opening the interview, explain that this case is one of a small number selected by chance for review and that the purpose of this review is to find out how well the Social Security program is working. Stress that this case was not selected because there was any question it. Tell them that the review consists of asking questions about their entitlement to Social Security benefits and that we may need to talk to others who have information about their entitlement. If necessary, point out that the Social Security Administration is authorized by law to review from time to time the entitlement of beneficiaries.

Page 1 of 20, Section I. Identifying and Review Information

Letters A through I.

Letter E – remove text “SSI Offset in Determining the Sample Dollars”

Reletter E through I accordingly.

Following letter I, insert the following text:

“NH Under FRA and Entitled to RIB in Closed Year…”

Page 2 of 20, Section II, Number Holder - DESK REVIEW

Letter A. Identity

Remove check box “Desk Review”

Letter B. No change.

Letter C. change text to read “Date of Birth and Citzenship”

Follow Letter C with the following:

1. Date of Birth and Proof Code on MBR Printout: ___ ____

2. Place of Birth: _____

3. MN:__________

4. Applications filed 12/1/96 or later: __US Citizen/National __Lawfully-Present Alien

5. Evidence/Documentation in Claims Folder/MCS Screens: ___

6. Evidence Needing Verification: ___

7. Date of Birth Established by Desk Review: ___

8. Citzenship/Alien Status Established by Desk Review: __

Remarks: __

Page 4 of 20, Section II, Number Holder - DESK REVIEW

Letter D. change text to read “Application” (formerly letter C on old form)

Follow Letter D with the following:

1. Benefit Type: __RIB ___DIB ___IF DIB, Established Onset Date: __

2. Date Claim Filed: ___

3. DOE (and MOEL Option Code if RIB): __

4. DOE Determined by Desk Review: __

Remarks: _____

Letter E. change text to read “Multiple Entitlement Involved” (formerly letter D on old form) ___Yes (complete below) ___No

Follow Letter E with the following:

1. Claim Number on Non-sampled SSN: ___

2. Scope of Review on Non-sampled SSN: ___

___Full Review ___Limited Review ___Not in Scope of Review

Letter F. change text to read “Other Claims Activity”

Follow Letter F with the following:

1. Did the NH ever file for any other benefits (including SSI)?

___Yes (Explain) ___No

2. Does the NH have any eligible children who have not filed for benefits?

___Yes (Explain) ___No

3. Unadjudicated Claims Issues: ___None Apply

__Unprocessed Application ___Deemed Filing

__Protective Filing __Open Application

__Partial Adjudication __Potential Entitlement (Leads)

__Delayed Claim __Misinformation

(Explain) __

Page 6 of 20, Section II, Number Holder, DESK REVIEW

Letter G. change text to read “Underpayment on sampled SSN needed to be addressed” (formerly F on old form)

__Yes __No

Letter H. change text to read “Recovery of Overpayment in Sample Month”(formally E)

__Yes __No

Letter I. text to read “SMI Determination” “__Not Applicable”(formally L)

The SMI determination, including the premium deduction and penalty amounts (if any), is correct. __Yes___No (Explain)

Letter J. text to read “Payment Amount” (formerly G on old form)

Follow Letter J. with the following:

1., 2., Same as text on old form in letter G.(remove the word “for”)

3. Payment Cycle Indicator (CYI): ____

4. Payment combined with other benefit: __ Yes __No

5. Check Amount Affected by Other Withholding (e.g., Medicare CD Premiums, Voluntary Tax Withholding, Garnishment, Treasury Offset Program, etc.)”

___Yes (Explain) __No

Page 8 of 20, Section II, Number Holder, ___Number Holder Never Married DESK REVIEW

Letter K, text to read “Marital History” (formerly Letter I on old form)

1., a, b, c, d, e, f, g, h, i, j, text all the same as old form.

2, a, b, c, d, e, f, g, h, i, j, text all the same as old form.

3, a, b, c, d, e, f, g, h, i, j, text all the same as old form.

Page 10 of 20, Section II, Number Holder - DESK REVIEW

Letter L, text to read “Computation Information” (formerly Letter J on old form)

1. Work issues,

fifth check box change to read “Annual Reports” (removed text “Incomplete Postings”)

sixth check box change to read “Other” (removed text Duplicate/Erroneous Postings)

removed check box “None Apply”

2. Military Service

Letters a., b., c, e, and f text the same as old form.

Letter d, change text to read “If MS prior to 1957, NH Receives/Eligible for Military/Civilian Federal Pension? __Yes __No (from old form text: NH Receives or is Eligible for Military/Civilian Federal Pension)

3. Railroad Employment (same as text on old form)

Letter a text same as old form

Letter b text change to “5 or more years” (from 7 or more years)

4. Prior Period of Disability (same as text on old form)

Letter a change to read “PPD Shown on MBR: Date of Onset:__ Term Date: __

Letter b change to read “Documentation in File: __

Letter c change to read “PPD Established by Desk Review: Date of Onset: __Term Date: __

Page 12 of 20, Section II, Number Holder - DESK REVIEW

5. Windfall Fall Eliminator Provision (same as text on old form)

Letter a text change to read Yes__(go to II.M.) (from Go to II.K.)

Letter b text change to read “NH is Entitled to a Foreign or Domestic Pension, or Lump Sum in Lieu of a Monthly Periodic Pension, Based on Work After 1956 Not covered by Social Security.” __Yes __No (Go to II.M)

Letter b, (1) – same as old form

Letter b, (2) – same as old form – (change text in parentheses to read “If either date is prior to 1986, go to 5.d”)

Letter b, (3) – change text to read “Other Exception to WEP Applies: __Yes __ No (if yes, go to 5.d)

Letter c – insert text to read “Information About the Pension”

Letter c (1) – insert text to read “Agency or Organization for Which the Pension is Received” (formerly Letter b (3))

Letter c (2) – insert text to read “Period(s) of Employment Upon Which the Pension is Based…”(formerly Letter b (4) on old form same text)

Letter c (3) – insert text to read “period(s) of employment after 1956 not covered…” (formerly Letter b(5) on old form same text)

Letter c (4) – insert text to read “Amount of the Pension for the First Month the Claimant is Concurrently Entitled to the Pension and the Social Security Benefit: Monthly Amount $ __ (Obtain proof if guarantee applies.)

Letter d – insert text to read “Evidence/Documentation in Claims Folder/MCS Screens: __”

Letter e – insert text to read “Evidence Needing Verification: ____”

Page 14 of _20_ , Section II, Number Holder - DESK REVIEW

M. – change text to read “Current DIB Entitlement” ___Not Applicable (Go to II.N.)

1. Periods of Disability (same as old form text)

1. a, insert text to read “Current Established Onset Date: ___

1. b., insert text to read “Date of Entitlement: ___”

1. c, insert text to read “ Prior Period of DIB: ___Yes (Complete Below) __No

Effect on Current Entitlement: __Waiting Period __Comps __Medicare __Other

2. Disability Related Work (same as old form)

2. a, insert text “Earning After Current Established Onset Date: __ Yes (complete below) __No”

2. b, insert text “Disability-Related Work Issues”

Insert check boxes – Trial Work Period __, Substantial Gainful Activity __, Unsuccessful Work Attempt__, Cessation__, Extended Period of Eligibility __, Termination__, Expedited Reinstatement ___, Other __,

2. c., insert “Evidence/Documentation in File ___

2. d, insert “Evidence Needing Verification: __”

3. Workers Compensation/Public Disability Benefit (WC/PDB)

3. same text as old form, reformatted with check boxes and lettered a, b, c, d, e, f, g

4. Child-Care Dropout (less than 3 Regular Drop-Out Yrs) __Yes __No (Got to II N.)

4.a, Child Under Age 3 lived with NH during a year that NH had no earnings __Yes __No

4. b, Documentation in Claims Folder/MCS Screens: ____

4. c, Evidence Needing Verification: ____

Page 18 of 20, Section II, Number Holder - DESK REVIEW

N. Fugitive Felon (formerly N. Criminal Activities on old form)

N. a, Are there any unsatisfied felony warrants for NHs arrest or for violations of probation/parole? __Yes __No (go to II O)

N. b, Evidence/Documentation in claims folder/MCS Screens:____

N. c, Evidence Needing Verification:_____

O. Criminal Activities – text same, reformatted to check boxes (formally N)

P. Representative Payee (same as old form) (formally M)

Page _20 of _20_ , Section II, Number Holder, CASE SUMMARY

Q. Consolidated Review Summary

___Desk and field review findings in agreement.

___Desk and field review findings are not in agreement. Indicate the section(s) where the disagreement. __Section A, __Section B, etc., through Section P.

Additional Development/Findings/Remarks: ___

Signature of Review(s)___ Date___

Desk Reviewer___ Date___

Field Reviewer___ Date___

Consolidated Reviewer___Date___

Pages _3, 5, 7, 9_of _20, Section II, Number Holder, change heading to read:

Section II, Number Holder, FACE-TO-FACE/TELEPHONE REVIEW (from Field/Telephone Review on old form)

A. Identity (remove text “SAMPLED NUMBER HOLDER”)

A. 1, Existence Verified by: (add text and checkbox) Photo ID____

C. change text to read: Date of Birth and Citizenship/Alien Status

D. change text to read: Application

E. change text to read: Multiple Entitlement

F. change text to read: Other Claims Activity

G. change text to read: Underpayment (formerly letter F on old form)

H. change text to read: Recovery of Overpayment in Sample Month

I. change text to read: SMI Determination

J. change text to read: Payment Amount (formerly letter G on old form)

K. change text to read: Marital History of Sampled Number Holder (formerly letter I)

Page _11, 13 of _20, Section II, Number Holder, FACE-TO-FACE/TELEPHONE REVIEW

L. Computation Information (formerly letter J on old form)

Change text to read: Evidence Obtained in Field Review (from Development/Findings/Remarks on old form)

Page _15, 17, 19 of _20, Section II, Number Holder, FACE-TO-FACE/TELEPHONE REVIEW

M. change text to read: Current DIB Entitlement (from Nonmedical Disability Information on old form); remove text and check box ___Not Applicable.

M., 1, 2, 3, 4, text same as old form

Add check box and text to 1-4: ___Evidence obtained in Field Review _____.

N., O., P., text same as old form, re-lettered to coincide with formatting on Desk Review.

The second column on the right-hand side of the workbook, titled “Consolidated Review,” we will reformat to coincide with the formatting in the sections referenced above.