Information Collection Request

The Ticket to Work and Self-Sufficiency Program, 20 CFR 411

ICR 201204-0960-004 · OMB 0960-0644 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form SSA-1370 Ticket to Work Individual Work Plan Form and Instruction Modified Available
Form SSA-L1377 Timely Progress Requirements to Pass Each 12-month Timely Progress Review Form and Instruction New Available
Form SSA-1392 Employment Network Payment Status Report Request Form Form and Instruction Removed Available
Form SSA-1401 Employment Network Split Payment Request Form Form Modified Available
Form SSA-1394 Employment Network Contract Change Form Form and Instruction Modified Repair queued
Form SSA-1365 State Agency Ticket Assignment Form Ticket to Work and Self-Sufficiency Program Form Modified Available
Form SSA-1398 Self-Employment Income (SEI) Form Beneficiary Quarterly Report Self-Employment Form and Instruction Modified Available
Form SSA-1396 Earnings Inquiry Request Form Form and Instruction Modified Available
Form SSA-1399 Auto Pay Request Form Form and Instruction Modified Available
Form SSA-1393 Employment Network Supplemental Earnings Statement Form and Instruction Modified Available
Form SSA-1389 EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request) Form and Instruction Modified Available
Form SSA-1391 Employment Network Payment Request Form Form and Instruction Modified Available
Form SSA-1375 Ticket to Work Progress Review Form Form Modified Available
Supporting Statement - 0644.docx Supporting Statement A Uploaded 2012-04-18 Available
Emergency Clearance Request Letter - 0644.docx Supplementary Document Uploaded 2012-04-18 Repair queued
Addendum - 0644.docx Supplementary Document Uploaded 2012-04-18 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
9680 a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370 Form and Instruction ModifiedTicket to Work Individual Work Plan
201989 a) 20 CFR 411.140(d)(2) - Ticket Assignability - Portal Other-Internet Screens New
201988 a) 20 CFR 411.140(d)(2) - Ticket Assignability - IVR Automated Telephone New
201987 a) 20 CFR 411.140(d)(2) - Ticket Assignability - Regular Telephone New
201843 f) 20 CFR 411.575 - Automatic Payments (SSA-1391 et al) New
201842 f) 20 CFR 411.575 - Portal Screens (SSA-1391 et al) New
201841 c) 20 CFR 411.200(b) - SSA-L1377 Portal Screens Other-Internet Screens New
201840 c) 20 CFR 411.200(b) - SSA-L1377 Request for Certification of Work Form and Instruction NewTimely Progress Requirements to Pass Each 12-month Timely Progress Review
201838 b) 20 CFR 411.145; 411.325 - Unassignments Portal Screens New
201837 a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370 Portal Screens Other-Internet Screens New
201836 a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1365 Portal Screens Other-Internet Screens New
191126 f) 20 CFR 411.575; SSA-1392 - EN Payment Status Report Request Form and Instruction RemovedEmployment Network Payment Status Report Request Form
190323 f) 20 CFR 411.560 - SSA-1401, Split Payment Situations Form ModifiedEmployment Network Split Payment Request Form
190204 i) 20 CFR 411.320 - SSA-1394, EN Contract Changes Form and Instruction ModifiedEmployment Network Contract Change Form
184502 a) 411.140(d)(3); 411.325(a); 411.150(b)(3) - SSA-1365 Form ModifiedState Agency Ticket Assignment Form Ticket to Work and Self-Sufficiency Program
184464 h) 20 CFR 411.435, 411.615, 411.625 - Dispute Resolutions Modified
184463 g) 20 CFR 411.325(f) - Periodic Outcomes Reporting Modified
184462 f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398 Form and Instruction ModifiedSelf-Employment Income (SEI) Form Beneficiary Quarterly Report Self-Employment
184462 f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398 Form and Instruction ModifiedEarnings Inquiry Request Form
184462 f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398 Form and Instruction ModifiedAuto Pay Request Form
184462 f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398 Form and Instruction ModifiedEmployment Network Supplemental Earnings Statement
184462 f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398 Form and Instruction ModifiedEN Services Certification Statement (For Use with Phase 1 Milestone 4 Request)
184462 f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398 Form and Instruction ModifiedEmployment Network Payment Request Form
184461 e) 20 CFR 411.325(d), 411.415 - Reporting Referral Agreement Modified
184460 d) 20 CFR 411.365, 411.505, 411.515 - Selecting a Payment System Modified
184459 c) 20 CFR 411.210(b) -Ticket-Use Status after Not Making Timely Progress Modified
184457 c) 20 CFR 411.200(b) - SSA-1375; SSA-L1373; SSA-L1374 Instruction Modified
184457 c) 20 CFR 411.200(b) - SSA-1375; SSA-L1373; SSA-L1374 Form ModifiedTicket to Work Progress Review Form
184456 c) 20 CFR 411.192(b)&(c) - Request to Place Ticket in Inactive Status Modified
184450 b) 20 CFR 411.535(a)(1)(iii) - VR Case Closures Unchanged
184449 b) 20 CFR 411.145 & 411.325 - Requesting Ticket Unassignments Modified
184447 a) 20 CFR 411.166; 411.170(b) - Elecronic Data Sharing Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
11/30/2012 6 Months From Approved 04/30/2013
333,793 0 206,926
73,673 0 63,502
0 0 0





Reginfo record details
25
table that charts list of burden
IC Title Form No. Form Name
a) 20 CFR 411.140(d)(2) - Ticket Assignability - IVR Automated Telephone
a) 20 CFR 411.140(d)(2) - Ticket Assignability - Portal
a) 20 CFR 411.140(d)(2) - Ticket Assignability - Regular Telephone
a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1365 Portal Screens
a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370 SSA-1370
a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370 Portal Screens
a) 20 CFR 411.166; 411.170(b) - Elecronic Data Sharing
a) 411.140(d)(3); 411.325(a); 411.150(b)(3) - SSA-1365 SSA-1365
b) 20 CFR 411.145 & 411.325 - Requesting Ticket Unassignments
b) 20 CFR 411.145; 411.325 - Unassignments Portal Screens
b) 20 CFR 411.535(a)(1)(iii) - VR Case Closures
c) 20 CFR 411.192(b)&(c) - Request to Place Ticket in Inactive Status
c) 20 CFR 411.200(b) - SSA-1375; SSA-L1373; SSA-L1374 SSA-1375
c) 20 CFR 411.200(b) - SSA-L1377 Portal Screens
c) 20 CFR 411.200(b) - SSA-L1377 Request for Certification of Work SSA-L1377
c) 20 CFR 411.210(b) -Ticket-Use Status after Not Making Timely Progress
d) 20 CFR 411.365, 411.505, 411.515 - Selecting a Payment System
e) 20 CFR 411.325(d), 411.415 - Reporting Referral Agreement
f) 20 CFR 411.560 - SSA-1401, Split Payment Situations SSA-1401
f) 20 CFR 411.575 - Automatic Payments (SSA-1391 et al)
f) 20 CFR 411.575 - Portal Screens (SSA-1391 et al)
f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398 SSA-1393, SSA-1391, SSA-1389, SSA-1399, SSA-1396, SSA-1398 ,   ,   ,   ,   ,  
f) 20 CFR 411.575; SSA-1392 - EN Payment Status Report Request SSA-1392
g) 20 CFR 411.325(f) - Periodic Outcomes Reporting
h) 20 CFR 411.435, 411.615, 411.625 - Dispute Resolutions
i) 20 CFR 411.320 - SSA-1394, EN Contract Changes SSA-1394

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 333,793 206,926 0 97,034 29,833 0
Annual Time Burden (Hours) 73,673 63,502 0 2,780 7,391 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
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