The Strengthening Protections for Social Security Benefi

Social Security Administration

Form Approved OMB No. 0960-0XXX

Strengthening Protections for Social Security Beneficiaries Act of 2018--Questionnaire
1. Please indicate the state you represent. Click here to select your state.
2. On average, how many reports of abuse do you receive annually?
3. Of the abuse reports filed in the last 12 months, how many reports were confirmed?
4. Please indicate the type of abuse reports your state is able to exchange with the Social

Security Administration (SSA). (Select all that apply)
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Physical abuse
Emotional abuse
Sexual abuse
Financial or material exploitation
Isolation
Abandonment
Neglect
Self-neglect
We are not able to exchange information (Please indicate the reason(s))
☐ Legal impediment
☐ Limited staff resources
☐ Does not have the technical capability
☐ Other (Please explain) Click here to enter text.
If you are unable to exchange information with SSA, stop here and submit
your responses.

5. Is there a consolidated record system for the entire state?
Click here to select Yes or No.
If you selected No, please explain Click here to enter text.
6. Please indicate the available report intake methods in your state. (Select all that apply)
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Online reporting system
Phone
Mail
Fax
Walk-in
Email

7. How often is your state able to ascertain if the victim receives SSA benefits?
Click here to select your response.

Social Security Administration

Form Approved OMB No. 0960-0XXX

8. How often is your state able to ascertain if the perpetrator is a representative payee?
Click here to select your response.
9. Please indicate the type of personal identifying information you collect for the victim.
(Select all that apply)
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Name
Date of birth
Social Security Number
Address
Phone number
Age
Gender
Other (Please specify) Click here to enter text.
None

10. Please indicate the type of personal identifying information you collect for the
perpetrator. (Select all that apply)
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Name
Date of birth
Social Security Number
Address
Phone number
Age
Gender
Other (Please specify) Click here to enter text.
None

11. Please indicate the type of information available for exchange with SSA. (Select all that
apply)
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Victim’s personal identifying information
Perpetrator’s personal identifying information
Perpetrator’s relationship to victim
Reported primary concern or allegation
Victim and/or perpetrator’s mental impairments
Victim and/or perpetrator’s physical impairments
Details of investigation result
Perpetrator criminal prosecution information
Other (Please specify) Click here to enter text.

Social Security Administration

Form Approved OMB No. 0960-0XXX

12. Does your state have the technical capability to send report data electronically to SSA?
Click here to select Yes or No.
If you selected No, please describe the available method to exchange data with SSA.
Click here to enter text.

Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. We estimate that it will take about
12 minutes to read the instructions, gather the facts, and answer the questions. Send
only comments regarding this burden estimate or any other aspect of this collection,
including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.