Supporting Statement - 0585

Supporting Statement for Form SSA-437

Complaint Form for Allegations of Discrimination in Programs or Activities

Conducted by the Social Security Administration

OMB No. 0960-0585

A. Justification

1. Introduction/Authoring Laws and Regulations

The SSA-437 obtains information from individuals who believe the operation of an agency-conducted program or activity violated their civil rights. 5 U.S.C. 301, 29 U.S.C. 794(a), and 42 U.S.C. 902(a)(5) of the United States Code, along with Executive Order 13166 and Executive Order 13160 authorize Social Security Administration (SSA) to collect this information. Section 504(a) of the Rehabilitation Act, 29 U.S.C. 794(a), provides that an executive branch agency shall not discriminate based on disability in programs and activities the agency conducts. The Federal Housekeeping statute, 5 U.S.C. 301, authorizes an agency head to prescribe regulations for the government of the agency and the performance of agency business. In addition, Section 702(a)(5) of the Social Security Act (Act) (42 U.S.C. 902(a)(5)) authorizes the Commissioner of the Social Security Administration, to prescribe such rules and regulations as the Commissioner determines necessary or appropriate to carry out the functions of the agency. Executive Order 13166 states that Federal agencies must provide individuals with limited English proficiency meaningful access to federally conducted programs and activities without unduly burdening the fundamental mission of the agency. Executive Order 13160 prohibits discrimination based on race, sex, color, national origin, disability, religion, age, sexual orientation and status as a parent in federally conducted education and training programs and activities.

2. Description of Collection

SSA collects information on Form SSA-437 to investigate and formally resolve complaints of discrimination based on disability, race, color, national origin (including limited English language proficiency), sex, sexual orientation, age, religion, or retaliation for having participated in a proceeding under this administrative complaint process in connection with an SSA program or activity. Individuals who believe SSA discriminated against them on any of the above bases may file a written complaint of discrimination. SSA uses the information to: (1) identify the complaint; (2) identify the alleged discriminatory act; (3) establish the date of such alleged action; (4) establish the identity of any individual(s) with information about the alleged discrimination; and (5) establish other relevant information that would assist in the investigation and resolution of the complaint. Respondents are individuals who believe SSA, or SSA employees, contractors, or agents in programs or activities conducted by SSA, discriminated against them.

2. Use of Information Technology to Collect the Information

The SSA-437-BK is available on SSA’s Internet website in an accessible, fillable PDF format. Individuals can fill out the form online, print the completed form, and send to SSA. SSA did not create an electronic version of form SSA-437 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 255 respondents complete the form manually. This is less than the GPEA cut-off of 50,000.

2. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not significantly affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently

If we did not use Form SSA-437, we would not be able to investigate incidents of alleged discrimination. We would also not be able to ensure that qualified individuals with disabilities are not excluded from; denied the benefits of; or subjected to discrimination solely on the basis of disability in the programs and activities SSA conducts. Because we only collect this information on an as‑needed basis, we cannot collect it less frequently. There are no technical or legal obstacles that prevent burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

SSA published the 60-day advance Federal Register Notice on April 4, 2016 at 81 FR 19283, and we did not receive any public comments in response to this notice. We published the 30-day Federal Register Notice on June 20, 2016 at 81 FR 39990. If we receive any comments in response to the 30-day Notice, we will forward them to OMB. We consulted with the National Center for Transgender Equality and civil rights advocates when revising this form.

8. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

8. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

8. Justification for Sensitive Questions

The nature of the discrimination alleged by the individual may require SSA to ask questions of a sensitive nature. For example, SSA may ask individuals who alleged discrimination based on religion to identify their religion, or we may ask individuals who alleged discrimination based on disability to identify their disability. SSA only requests information directly relating to the allegations the individual raises, and that SSA deems necessary to fully investigate the complaint. SSA does not require an individual to file complaints of discrimination; however, if individuals choose to do so, and they want a decision on, or resolution of a complaint, we may, on occasion, request them to provide information they may otherwise consider sensitive.

8. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Total Annual Burden (hours)
SSA-437	255	1	60	255

The total burden for this ICR is 255 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

13. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $7,500. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request

There are no changes to the public reporting burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise usable forms with expired OMB approval dates, avoiding Government waste .

18. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.