Addendum to the Supporting Statement for 0960-0585

Addendum to the 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

Revision to the Collection Instrument

• Change #1: We are editing the Instructions section. On pages 1 and 2 of the current form, please delete the current instructions and replace with the following:

PURPOSE OF THIS FORM: The purpose of this form, SSA-437-BK, is to help you file a complaint of discrimination about a program or activity conducted by the Social Security Administration (SSA).

SSA POLICY: SSA policy requires us to conduct our programs and activities in a way that does not discriminate on the basis of: race, color, national origin (including limited ability to communicate in English), religion, sex (including sexual orientation and gender identity), disability, age, or parental status. No SSA officer, employee or agent may intimidate, threaten, harass, coerce, discriminate or otherwise retaliate against anyone who has filed a complaint of alleged discrimination or who has participated in any manner in an investigation or other proceeding raising allegations of discrimination.

FILING A COMPLAINT OF DISCRIMINATION: If you think that an SSA employee or Administrative Law Judge (ALJ) acted upon your claim based on bias or discrimination instead of the facts of your case, you may file a complaint of discrimination by using this form. Instead of using this form, you may write a letter stating the same information required by this form. If your letter is missing information, we will send you a copy of this form. We investigate complaints of discrimination that are complete, timely and within our jurisdiction.

Do not file a complaint of discrimination if you experienced a customer service problem not related to discrimination. Instead, contact SSA at https://faq.ssa.gov/ics/support/ticketnewwizard.asp?style=classic&type=feedback.

COMPLAINTS ABOUT DECISIONS ON CLAIMS FOR PROGRAM BENEFITS: Do not file a complaint of discrimination if your complaint concerns a benefits decision you disagree with. If you want to ask SSA to change its decision about your benefits claim under a program SSA administers (such as DIB, SSI, child’s benefits, widow’s benefits, or retirement), you must follow the procedures and deadlines for appealing the decision as described in the notice of appeal rights included with the decision. If you believe SSA’s benefits decision was based on discrimination, you must state this in your appeal and provide the facts on which you base your allegation.

IMPORTANT: If you disagree with an action SSA took on a claim for benefits, our program rules require you to appeal the action within a specific time period. Filing a complaint of discrimination using this form (or a letter stating the same information required by this form) to complain that an SSA employee or Administrative Law Judge (ALJ) acted upon your claim for benefits based on bias or discrimination instead of the facts of your case will not extend the deadline for filing an appeal.

COMPLAINTS ABOUT EMPLOYMENT WITH SSA: Do not use this form if your complaint concerns employment with SSA. Instead, you must contact an SSA Equal Employment Opportunity (EEO) Counselor within 45 days of the action you believe was based on discrimination. Contact an EEO Counselor at (866) 744‑0374 or through SSA's Office of Civil Rights and Equal Opportunity intranet website.

FILING DEADLINE: You must file a complaint of discrimination within 180 days of the action you allege was based on discrimination. If the action took place more than 180 days ago, you must explain why you waited to file the complaint. SSA will waive the 180-day deadline if we believe you had good cause for filing late. We must dismiss complaints filed late without good cause.

FILING A COMPLAINT BY MAIL OR EMAIL: To file a complaint of discrimination, you or someone helping or representing you, should complete a signed and dated copy of this form (or a letter stating the same information required by this form). If your complaint of discrimination is incomplete or unsigned, we will send it back to you for correction which will delay our consideration of your complaint. Save a copy of your completed complaint of discrimination. Mail the original to the appropriate regional SSA office listed at the end of the instructions section. You may choose to email your complaint of discrimination as an attachment to [email protected]. Communication by unencrypted email presents a risk that unauthorized third parties could intercept your personally identifiable information.

IDENTIFYING THE APPROPRIATE REGIONAL OFFICE. If you are mailing your complaint of discrimination, please send it to the regional office covering the state where the alleged discrimination occurred. If you allege discrimination occurred when interacting with SSA online, by email, or by telephone with SSA’s centralized customer service support, please use the regional office covering the residence of the person allegedly discriminated against.

QUESTIONS. For questions about or assistance with the civil rights discrimination complaint process, you or someone helping or representing you may reach us by email as described above or by telephone, toll-free, at (866) 574-0374. You may also send a letter to the appropriate regional SSA office.

Justification #1: Revising the instructions will help reduce the frequency of complainants using the form for inappropriate purposes. The shorter instructions are also revised to be clearer and to better apply the plain writing style.

• Change #2: On page 3 of the current form, we will reverse the name and address blocks for the two separate individuals at Question 1 and Question 2.

Justification #2: This will reduce user error in completing the form. The current form is counterintuitive in asking for the name of the person completing the form before the name of the person alleging the civil rights violation. People completing the form for someone else would most likely begin by inputting the name of the person they are helping rather than their own names.

• Change #3: The new Question 1 will prompt as “Person allegedly discriminated against.”
  
  

Justification #3: This will reduce user error in completing the form. The current form is counterintuitive in asking for the name of the person completing the form before the name of the person alleging the civil rights violation. People completing the form for someone else would most likely begin by inputting the name of the person they are helping rather than their own names.

• Change #4: The new Question 1 will add an instruction prompting, “For additional persons, please provide the information on a separate sheet.”

Justification #4: This prevents confusion when multiple individuals are making civil rights discrimination allegations on the same form. Otherwise, multiple names, sets of contact information, and SSNs could be squeezed together on the form in the same area.

• Change #5: The new Question 1 will add an SSN section.

Justification #5: SSA needs the SSN of the complainant, not the person helping the complainant.

• Change #6: Change “Daytime phone number where you can be reached” to “Daytime phone number.”
  
  

Justification #6: This will delete unnecessary verbiage.

• Change #7: The new Question 2 will prompt “Person completing this form, if different from the person identified in question 1.”

Justification #7: This will reduce user error in completing the form. The current form is counterintuitive in asking for the name of the person completing the form before the name of the person alleging the civil rights violation. People completing the form for someone else would most likely begin by inputting the name of the person they are helping rather than their own names.

• Change #8: The new Question 2 will delete the SSN section.

Justification #8: SSA does not need the SSN of anyone helping the complainant fill out the form.

• Change #9: The new Question 2 will add a phone number section: “Daytime phone number.”

Justification #9: SSA investigation of the allegation entails contacting the person who knows about the incident of alleged discrimination. Complainants who need help completing the form are often not able to communicate about the investigation and rely upon the person who helped complete the form.

• Change #10: We are adding a shorter policy statement. On page 3 of the current form, and Question 4, we will replace the current text with the following:
  
  It is against SSA policy for a program conducted by SSA to discriminate against you based on your race, color, national origin (including limited ability to communicate in English), religion, sex (including sexual orientation and gender identity), disability, age, and parental status. (Note: Not all of these bases apply to all of SSA's programs.) It also is against SSA policy to retaliate against you because you filed a discrimination complaint or to retaliate against anyone who assisted you in filing a complaint. Please tell us why you believe you were discriminated against.

Justification #10: This version is slightly shorter. It also eliminates the advanced vocabulary of “proficiency,” which is not plain language and is a word too difficult for a person challenged to communicate in English.

• Change #11: On page 6 of the current form, change “American Indian” to “Native American.”

Justification 11: We changed this to be politically correct. This term includes Alaska Natives as well.

• Change #12: Change signature blocks to match newly reversed Questions 1 and 2.

Justification #12: Agency needs the signature of the complainant even if someone is helping him complete the form.

• Change #13: On page 6 of the current form, at Question 14, change “Signature” to “Signature of person allegedly discriminated against.”
  
  

Justification #13: Agency needs the signature of the complainant even if someone is helping him complete the form.

• Change #14: On page 6, at item 14, please eliminate the paragraph of instruction that reads:
  
  You must sign and date the complaint. If you are filing the complaint for someone else, you must also get that person to sign and date it. If you are not able to get that person to sign the complaint, please explain why, and be sure to complete question #2, so that we are able to contact that person. If you send the complaint to us by email, be sure to attach a signed copy of the complaint.
  
  We will replace it with this instruction:
  
  If someone is helping or representing the person allegedly discriminated against (identified in Question 1) to file this complaint of discrimination, both of you must sign and date this form. If the person allegedly discriminated against is not able to sign and date this complaint form, please explain why, and be sure to complete Question 1 so we can contact that person.
  
  

Justification #14: We are giving clearer instructions without repeating information provided in the new main instructions section.

• Change #15: We will add a second signature area prompting, “Signature of person allegedly discriminated against.”

Justification #15: Agency needs the signature of the complainant even if someone is helping him complete the form.

• Change #16: On page 6 of the current form, we will delete the information under section titled How to File This Complaint.
  
  

Justification #16: This information is covered in the new instructions. Email has superseded the fax filing option.

• Change #17: Add a page of mailing addresses for the 10 regional offices. (Address list provided at the end of this summary.)

Justification #17: OGC management and the regional offices agreed to change the process so members of the public will send complaints directly to the regions that investigate the allegations of discrimination. The new process will save time by eliminating the unnecessary step of headquarters organizing and redistributing each complaint.

REGION 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

Civil Rights Coordinator

Office of General Counsel, Region 1

Social Security Administration

J.F.K. Federal Building, Room 625

15 New Sudbury Street

Boston, MA 02203

REGION 2: New York, New Jersey, Puerto Rico, U.S. Virgin Islands

Civil Rights Coordinator

Office of the General Counsel, Region 2

Social Security Administration

26 Federal Plaza

Room 3904

New York, NY 10278

Region 3: Delaware, Maryland, Pennsylvania, Virginia, West Virginia, the District of Columbia

Civil Rights Coordinator

Office of the General Counsel, Region 3

Social Security Administration

PO Box 41777

Philadelphia, PA 19101

Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

Civil Rights Coordinator

Office of the General Counsel, Region 4

Social Security Administration

Atlanta Federal Center

61 Forsyth Street

Suite 20T45

Atlanta, GA 30303

REGION 5: Ohio, Michigan, Illinois, Indiana, Wisconsin, Minnesota

Civil Rights Coordinator

Office of the Regional Chief Counsel, Region 5

Social Security Administration

Social Security Administration

200 West Adams Street, 30th Floor

Chicago, IL 60606

REGION 6: Arkansas, Louisiana, Oklahoma, New Mexico, Texas

Civil Rights Coordinator

Office of the General Counsel, Region 6

Social Security Administration

1301 Young Street, Suite A-702

Dallas, TX 75202-5433

REGION 7: Iowa, Kansas, Missouri, and Nebraska

Civil Rights Coordinator

Office of the General Counsel, Region 7

Social Security Administration

601 East 12th Street, Room 965

Kansas City, MO 64106

REGION 8: Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

Civil Rights Coordinator

Social Security Administration

Office of the General Counsel, Region VIII

1961 Stout Street, Suite 04-169

Denver, CO 80294

REGION 9: Arizona, California, Nevada, Hawaii, Guam, American Samoa, Saipan

Civil Rights Coordinator

Office of the General Council, Region 9

Social Security Administration

160 Spear Street, Suite 800

San Francisco, CA 94105-1545

REGION 10: Alaska, Idaho, Oregon, and Washington

Civil Rights Coordinator

Office of the General Counsel, Region 10

Social Security Administration

701 Fifth Avenue,

Suite 2900, M/S 221A

Seattle, WA 98104-7075

• Change #18: SSA intends to provide Form SSA-437-BK in a fillable PDF file on our website, in place of the non-fillable PDF version we currently provide. We will make all form entries fillable.
  
  Justification #18: This change will allow the respondents to continue to print and complete the form by hand, or, alternatively, complete the form using a computing device, such as a personal computer or handheld (mobile) device, print, and submit the form to SSA for processing.