Supporting Statement for Form SSA-765
Response to Notice of Revised Determination
20 CFR 404.913-404.914, 404.992(b), 416.1413-416.1414, and 416.1492(d)
OMB No. 0960-0347
Justification
Introduction/Authoring Laws and Regulations
When the Social Security Administration (SSA) determines (1) claimants for initial disability payments do not actually have a disability, or (2) current disability recipients’ records show their disability ceased, SSA notifies the disability recipients of this decision. In response to this notice, the affected claimants and disability recipients have the following recourse: (1) they may request a disability hearing to contest SSA’s decision, and (2) they may submit additional information or evidence for SSA to consider. The legal authority governing these actions is the Social Security Act, sections 205(a) and 1631(e)(1)(A); and the Code of Federal Regulations, sections 20 CFR 404.913‑410.914; 416.1413-416.1414; 404.992(b); and 416.1492(d). Disability recipients, and their representatives use Form SSA‑765, the Response to Notice of Revised Determination, to accomplish these two actions.
Description of Collection
Disability claimants, recipients, and their representatives use Form SSA-765 to (1) request a hearing on their claim, or (2) submit additional information and evidence for SSA to consider in making our determination. If respondents request the first option, SSA’s Disability Hearings Unit uses the form to schedule a hearing; ensure an interpreter is present, if required; and ensure the disability recipients or claimants, and their representatives, receive a notice about the place and time of the hearing. If respondents choose the second option, SSA uses the SSA-765 and other evidence to reevaluate the claimants’ or recipients’ case, and determine if the new information or evidence will change SSA’s decision. The respondents are disability claimants, current disability recipients, or their representatives.
Use of Information Technology to Collect the Information
This form, available as a fillable PDF, falls below the 50,000 respondent threshold established by SSA's Government Paperwork Elimination Act plan, so we did not create an electronic version.
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 SSA did not conduct this information collection, denied disability applicants and current disability recipients whose payments SSA plans to stop would have no means of requesting a hearing or submitting additional information, which would be a violation of the regulations cited in #1 above. Because SSA only collects this information under the circumstances mentioned above, we cannot collect it less frequently. There are no technical or legal obstacles to 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 October 3, 2018, at 83 FR 49965 and we received no public comments. The 30-day FRN published on January 25, 2019, at 84 FR 371. 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 payments or gifts to the respondents.
Assurance 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 1,925 respondents take 30 minutes each to complete Form SSA-765 each year, as shown in the chart below:
Modality of Completion |
Number of Respondents |
Frequency of Response |
Average Burden Per Response (minutes) |
Estimated Total Annual Burden (hours) |
SSA-765 |
1,925 |
1 |
30 |
963 |
The total burden for this ICR is 963 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 Respondent
This collection does not impose a known cost burden on the respondents.
Annual Cost to the Federal Government
The annual cost to the Federal Government is approximately $2,965. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time; and (3) systems development, updating, and maintenance costs.
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 this information collection.
Displaying the OMB Approval Expiration Date
For the paper Form SSA-765, we will not publish 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.
For the Internet version of Form SSA-765, SSA does not request an exception to the requirement to display the OMB approval expiration date.
Exception 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 | Supporting Statement for Form SSA-765 |
| Author | 030060 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |