Workers' Compensation/Public Disability Benefit Questionnaire

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-546 Workers' Compensation/Public Disability Benefit Questinnaire	Form	Modified	Available
Form SSA-546 Workers compensation Public Disability Benefit Questionnaire	Form	Modified	Available
Addendum 0247.doc	Supplementary Document	Uploaded 2011-11-29	Available
Supporting Statement 0247 (revised).doc	Supporting Statement A	Uploaded 2012-02-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9165	Workers' Compensation/Public Disability Benefit Questionnaire	Other-MCS screens	Modified
9165	Workers' Compensation/Public Disability Benefit Questionnaire	Form	Modified	Workers' Compensation/Public Disability Benefit Questinnaire
188508	Workers Compensation Public Disability Benefit Questionnaire	Form	Modified	Workers compensation Public Disability Benefit Questionnaire

ICR Details

OMB Control No: 0960-0247	ICR Reference No: 201111-0960-001
Status: Historical Active	Previous ICR Reference No: 200902-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Workers' Compensation/Public Disability Benefit Questionnaire
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: 03/26/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/22/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2015	36 Months From Approved	05/31/2012
Responses	250,000	0	250,000
Time Burden (Hours)	62,500	0	62,500
Cost Burden (Dollars)	0	0	0

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Abstract: Section 224 of the Social Security Act provides for the reduction of disability insurance benefits (DIB) when the combination of DIB and any workers' compensation (WC) and/or certain Federal, State or local public disability benefits (PDB) exceeds 80% of the worker's average current earnings. SSA uses Form SSA-546 to collect the data necessary to determine whether or not the worker's receipt of WC/PDB payments will cause a reduction of DIB. The respondents are applicants for Title II DIB.

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Authorizing Statute(s): US Code: 42 USC 424 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 72994	11/28/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 6853	02/09/2012
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Workers Compensation Public Disability Benefit Questionnaire	SSA-546	Workers compensation Public Disability Benefit Questionnaire
Workers' Compensation/Public Disability Benefit Questionnaire	SSA-546	Workers' Compensation/Public Disability Benefit Questinnaire

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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	250,000	250,000	0	0	0	0
Annual Time Burden (Hours)	62,500	62,500	0	0	0	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:

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Annual Cost to Federal Government: $1,350,260

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: 02/22/2012

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