PCS Questions Chart Showing Affected ICRs

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

Individual
Information
Screen
Individual
Information
Screen
Individual
Information
Screen
Individual
Information
Screen
Individual
Information
Screen
Individual
Information
Screen
Protective
Filing Screen

PCS Question

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

iClaim
(online
application)
OMB No.
0960-0618

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

Is John Doe answering
the questions?

Is John Doe legally
incompetent?

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

Both SSI applications provide
instructions to answer the
questions for name of
person/agency and
relationship to the claimant if
the individual is applying on
behalf of someone else.
These three questions
represent the instructions.

Is John Doe inquiring on
his or her own behalf?
Is someone else
inquiring on John Doe
behalf?
What is the inquiring
individual’s relationship
to John Doe?
Name or Organization’s
Name

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

X

X

X

X

X

This is not an application question. We are asking this question to determine if the individual inquiring meets the respondent criteria (legally incompetent adult with a
legal guardian) for the PCS.

This screen is for internal use only. Questions are for the SSA employee and not the public.

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

PCS Question

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

iClaim
(online
application)
OMB No.
0960-0618

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

Person
Information
Screen

This screen provides information previously collected and stored for the technician’s reference. The technician is still required to ask the individual the applications questions
that collect name, date of birth, social security number, citizenship or alien status, contact information and preferred language. The SSA employee can over key the information
if it differs from what the individual provides.

Person
Information
Screen

SSN

X

X

X

Person
Information
Screen

Name

X

X

X

X

Person
Information
Screen

Other Names Used

X

X

X

X

Person
Information
Screen

Sex

X

X

X

X

X

X

X

X

Person
Information

Birth Date

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

PCS Question

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

X

X

X

iClaim
(online
application)
OMB No.
0960-0618

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

X

X

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

X

X

Screen
Person
Information
Screen

Birth Place

Person
Information
Screen

Parent/Mother’s name
at birth

This data is only for the SSA employee’s reference and is not a PCS question.

Person
Information
Screen

Parent/Father’s name at
birth

This data is only for the SSA employee’s reference and is not a PCS question.

Person
Information
Screen

Citizenship Country

X

X

X

X

X

X

Person
Information
Screen

U.S. Citizenship Basis

X

X

X

X

X

X

X

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

PCS Question

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

iClaim
(online
application)
OMB No.
0960-0618

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

Person
Information
Screen

Start Date

X

X

X

Person
Information
Screen

End Date

X

X

X

Person
Information
Screen

Address

X

X

X

X

X

X

X

X

X

X

X

Person
Information
Screen

Primary Phone Number

X

X

X

X

X

X

X

X

X

X

X

Person
Information
Screen

Alternate Phone
Number

This is not a PCS or application question. It is displayed in PCS because it is linked with the contact information that includes address and phone number.

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

PCS Question

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

iClaim
(online
application)
OMB No.
0960-0618

Person
Information
Screen

Receive Text Message

Person
Information
Screen

Receive Voice Message

Person
Information
Screen

Email

Person
Information
Screen

Spoken Language
Preference

X

X

X

X

Person
Information
Screen

Written Language
Preference

X

X

X

X

Person
Information

Accommodations?

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

This is not a PCS or application question. It is displayed in PCS because it is linked with the contact information that includes address and phone number.

This is not a PCS or application question. It is displayed in PCS because it is linked with the contact information that includes address and phone number.

X

X
The SSA-8000
ask for the

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

PCS Question

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

iClaim
(online
application)
OMB No.
0960-0618

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

Screen

Residence
Screen
Residence
Screen
Residence
Screen

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

type of mail
the claimant
wants to
receive from
us based on
his or her
visual
impairment.
Do you live at this
address?
Residence Address
When did you begin
living at this address?

X
X
Required for
Uninsured
Medicare
only claims
for noncitizens per
CMS-18F5
(OMB 09380251)

X

X

X

X

X

X

X

X

X

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

PCS Question

Residence
Screen

What date did you
establish residency in
the United States
In the last 14 months,
have you been unable
to work due to illness,
injuries, or conditions
that is expected to last
for at least 12 months
or will result in death?
Are you blind or do you
have low vision even
with glasses or contact
lens?
Have you been
diagnosed with End
Stage Renal Disease?

Disability
Screen

Disability
Screen

Disability
Screen

Disability
Screen

What date did you
become disabled and
unable to work

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

iClaim
(online
application)
OMB No.
0960-0618

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

X
X

X

X

X

X

X

X

X

X

X

X

X

This is not an application question. Normally an individual contacts SSA to file for Medicare based on having End Stage Renal Disease (ESRD). Because PCS is
identifying all potential entitlements, we need to ask this question to ensure PCS identifies individuals who are only eligible for Medicare based on ESRD requirements.

X

X

X

X

X

X

X

X

X

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

PCS Question

Disability
Screen

Do you have a disabling
condition that was
established prior to
attaining age 22?
Do you have a parent
who is age 62 or older,
unable to work because
of illness, injuries or
conditions, or
deceased?
Parent 1 SSN

Disability
Screen

Disability
Screen
Disability
Screen
Earnings Screen

Earnings Screen
Earnings Screen

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

iClaim
(online
application)
OMB No.
0960-0618

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

Parent 2 SSN
Have you worked under
any other Social Security
Numbers (SSN)?
What other SSN(s) have
you used?
Did you work last year
or any time this year?

X

X

X

X

X

X

X

X

X

X

X

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

X

X

X

X

X

X

X

X

X

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

PCS Question

Earnings Screen

Last year’s earnings:
Type (wages/selfemployment) and
Amount.
Current earnings: Type
(wages/selfemployment) and
Amount.
Are you currently
working?
Current earnings: Type
(wages/selfemployment) Amount,
and Frequency
Have you worked
and/or reported
earnings in a foreign
country?
In what foreign country
have you reported
earnings?

Earnings Screen

Earnings Screen
Earnings Screen

Earnings Screen

Earnings Screen

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

iClaim
(online
application)
OMB No.
0960-0618

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

X

X

X

X

X

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

Earnings Screen

Earnings Screen
Earnings Screen

PCS Question

Did you serve in the
military service before
1968?
Start and End Dates

Have you worked for
the Railroad 5 years or
more?
Earnings Screen Are you receiving or
eligible to receive a
Railroad pension or
annuity?
Earnings Screen Have you received
Railroad Unemployment
Insurance Act benefits
in the last 18 months?
Earnings Screen Has your spouse or prior
spouse worked for the
Railroad for 5 years or
more?
Earnings Screen Is your spouse or prior

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

iClaim
(online
application)
OMB No.
0960-0618

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

X

X

X

X

X

X

X

X

X

X

X

X

X

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

X

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

X
X

X

X

X

X

X

X

This question is not asked in our applications because it is information that an SSA employee needs to determine prior to taking a claim. If the individual has received
Railroad Unemployment in the last 18 months, filing for Social Security benefits could have an adverse effect on his or her Railroad Unemployment. Therefore, the
SSA employee will instruct the individual to contact the Railroad Board prior to filing for Social Security benefits.

X

X

X

X

X

X

X

X

X

X

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

Insured Status
Screen
Children Screen
Children Screen

Children Screen

Children Screen

PCS Question

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

iClaim
(online
application)
OMB No.
0960-0618

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

spouse receiving or
eligible to receive a
Railroad pension or
annuity?
The Insured Status Screen is for internal use only. SSA employees refer to the individual’s insured status data when discussing earnings, disability onset dates, month of entitlements and
possibly filing dates.
Do you have any
X
children?
Are any of your children
X
unmarried and under
The Retirement, Husband’s/Wife’s and
age 18?
Are any of your children Disability Insurance Applications combine
X
these questions. The instructions for
unmarried, age 18-19,
listing a child’s name includes the criteria
and still attending
provided in these individual child
elementary school or
questions.
secondary school
(below college level)
full-time?
Did any of your children
X
become disabled prior
to the age 22?

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

PCS Question

Supplemental
Security
Income Screen
Supplemental
Security
Income Screen

Do you wish to apply for
Supplemental Security
Income?
Since the first moment
of the month of
mm/dd/yyyy, do you
own, or does your name
appear on any
resources, either
List your resources with
value.

Supplemental
Security
Income Screen
Supplemental
Security
Income Screen

At any time since
mm/dd/yyyy, have you
or received any type of
income, or do you
expect to receive any
type of income in the
next 3 months?

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

iClaim
(online
application)
OMB No.
0960-0618

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

X

X

X

X

X

X

X

ATTACHMENT 1 – TABLE OF PCS QUESTIONS WITH CORRESPONDING TITLE II AND TITLE XVI APPLICATIONS

Screen name

Supplemental
Security
Income Screen

PCS Question

List your Income and
value.

Retirement
Insurance
Benefits
(SSA-1)
OMB No.
0960-0618

Husband’s
or Wife’s
Insurance
Benefits
(SSA-2)
OMB No.
0960-0618

Disability
Insurance
Benefits
(SSA-16)
OMB No.
09600618

iClaim
(online
application)
OMB No.
0960-0618

Widow(er)’s
Insurance
Benefits
(SSA-10)
OMB No.
0960-0004

Mother
or Father
Insurance
Benefits
(SSA-5)
OMB No.
09600003

Child
Insurance
Benefits
(SSA-4)
OMB No.
09600010

Parent’s Insurance
Benefits
(SSA-7)
OMB No. 09600012

Lump Sum
Death
Payment
(SSA-8)
OMB No.
0960-0013

Supplemental
Security
Income (SSI)
(SSA-8000)
OMB No.
0960-0229

SSI
(Abbreviated
or Deferred)
(SSA-8001)
OMB No.
0960-0444

X

X