Expanded Monitoring Site Review: Beneficiary Interview Form

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

OMB: 0960-0633

IC ID: 178591

Information Collection (IC) Details

View Information Collection (IC)

Expanded Monitoring Site Review: Beneficiary Interview Form
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 404.2035 20 CFR 416.708 20 CFR 404.2065 20 CFR 416.665 20 CFR 416.701

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   Fillable Printable
Other-Revised PA Statement Revised PA Statement.pdf No   Fillable Printable

Income Security General Retirement and Disability

 

21,772 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 21,772 0 0 13,479 0 8,293
Annual IC Time Burden (Hours) 3,629 0 0 2,247 0 1,382
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Current SSA-639 SSA-639 - Current.pdf 10/17/2018
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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