Justification
Introduction/Authoring Laws and Regulations
Section 205(b) of the Social Security Act (Act) and sections 20 CFR 404.913-404.914 and 20 CFR 416.1413-416.1414 of the Code of Federal Regulations (CFR) allow for an evidentiary administrative hearing at the reconsideration level of appeal for beneficiaries, or recipients, who received an initial continuing disability review (CDR), or reopened, or revised, determination or decision that a disability did not exist or ceased. 20 CFR 404.916(b)(5) and 20 CFR 416.1416(b)(5) of the CFR informs beneficiaries and recipients of the effects of the decision to waive the right to a disability hearing with a Disability Hearing Officer (DHO).
Description of Collection
Claimants for Social Security disability payments or their representatives can use Form SSA-773-U4 to waive their right to appear at a disability hearing. Respondents complete the SSA-773-U4 through a personal interview with field office (FO) staff; Disability Determinations Service (DDS) staff; or Disability Hearing Unit (DHU) staff to insure the individual understands the due process rights associated with the decision to waive personal appearance at a disability hearing by a Disability Hearing Officer (DHO). We conduct these personal interviews either in person or via telephone with the claimants or their representatives. Once we obtain the information on the SSA-733-U4, the DHO uses the signed form as a basis for not holding a hearing, and for preparing a written decision on the claimant’s request for disability payments based solely on the evidence of record. The respondents are disability claimants for Social Security benefits or SSI payments, or their representatives, who wish to waive their right to appear at a disability hearing.
Use of Information Technology to Collect the Information
Form SSA-773-U4 is available through the Internet in a portable document format
(PDF) for FO, DDS, or DHU staff to complete through a personal interview with the claimants or their representatives. Once FO, DDS or DHU staff complete the interview, they print the form and ask the respondent to sign it. In the case of telephone interviews, the staff member mails the completed form to the respondent for signature. The respondent mails the signed, completed form to SSA. SSA did not create an electronic version of Form SSA-773-U4 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 200 respondents complete the form annually. This is less than the GPEA cut-off of 50,000.
Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it preclude duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-773, beneficiaries and recipients would not have a structured format to use to request a waiver to appear at a disability hearing, or documentation informing them of the effects of their decision to waive that right. SSA would also lack documentation of the individual’s informed decision. Since SSA requests this information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles that prevent burden reduction.
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.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on February 1, 2018, at 83 FR 4722, and we received no public comments. The 30-day FRN published on May 9, 2018 at 83 FR 21328. If we receive any comments in response to this Notice, we will forward them to OMB.
Payment or Gifts to Respondents
SSA does not provide payment or gifts to the respondents.
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.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Approximately 200 respondents take 3 minutes each to complete Form SSA‑773‑U4. Accordingly, the burden is 10 hours:
Modality of Completion |
Number of Respondents |
Frequency of Response |
Average Burden Per Response (minutes) |
Total Estimated Annual Burden (hours) |
SSA-773-U4 |
200 |
1 |
3 |
10 |
The total burden for this ICR is 10 hours. We based this figure on current management information data, and it represents burden hours. We did not calculate a separate cost burden.
Annual Cost to the Respondents (Other)
This collection does not cause a known cost burden on the respondents.
Annual Cost To Federal Government
The annual cost to the Federal government for the form is approximately $331. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; and (2) SSA employee (e.g., field office, 800 number, DDS or DHU staff) information collection and processing time.
Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
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 useable forms with expired OMB approval dates, avoiding Government waste.
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).
Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Title of Information Collection and Form Number(s) |
| Author | Naomi |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |