Workers' Compensation/Public Disability Benefit Questionnaire

Forms and Documents

Document Name	Status
Form SSA-546 Workers Compensation Public Disability Benefit Questionnaire Form	Removed
Addendum 0247 (revised).doc Supplementary Document	2014-09-02
Supporting Statement (revised).doc Supporting Statement A	2014-10-31

IC Document Collections

IC ID	Document Title	Status
9165	Workers' Compensation/Public Disability Benefit Questionnaire Other-MCS screens	Modified
188508	Workers Compensation Public Disability Benefit Questionnaire Form	Removed

ICR Details

OMB Control No: 0960-0247	ICR Reference No: 201407-0960-014
Status: Historical Active	Previous ICR Reference No: 201111-0960-001
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: 12/22/2014
	Date Received in OIRA: 11/03/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2017	36 Months From Approved	03/31/2015
Responses	248,000	0	250,000
Time Burden (Hours)	62,000	0	62,500
Cost Burden (Dollars)	0	0	0

---

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.

---

Authorizing Statute(s): US Code: 42 USC 424 Name of Law: 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:
	79 FR 51387	08/28/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 64872	10/31/2014
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

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

---

ICR Summary 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	248,000	250,000	0	-2,000	0	0
Annual Time Burden (Hours)	62,000	62,500	0	-500	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There has been a decrease in burden hours. The decrease is due to the removal of the Paper SSA-546. Field Office technicians use the electronic WC/PDB screens in the Modernized Claims Systems to collect the information.

---

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: 11/03/2014

---