Expanded Monitoring Site Review: Beneficiary Interview Form

Site Review Questionnaires for Volume and Fee-for-Service Payees and Beneficiary Interview Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0633 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-639 Expanded Monitoring Site Review: Beneficiary Interview Form Form
SSA-639 Expanded Monitoring Site Review Beneficiary Review Form SSA-639 Revised.pdf Form
SSA-639 Current Version.pdf Current SSA-639 IC Document

Information Collection (IC) Details

IC Title:	Expanded Monitoring Site Review: Beneficiary Interview Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.2035 20 CFR 416.708 20 CFR 404.2065 20 CFR 416.665 20 CFR 416.701

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-639	Expanded Monitoring Site Review Beneficiary Review Form	SSA-639 Revised.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,293	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	8,293	-1,048	9,341
Annual IC Time Burden (Hours)	1,382	-175	1,557
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-639	SSA-639 Current Version.pdf	10/01/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.