State Mental Institution Policy Review

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-9584-BK State Mental Instintution Policy Review	Form	Modified	Available
Addendum - 0110.docx	Supplementary Document	Uploaded 2020-08-24	Available
Addendum - 0110.docx	Supplementary Document	Uploaded 2020-08-24	Repair queued
Supporting Statement -0960- 0110 (Final).docx	Supporting Statement A	Uploaded 2024-09-16	Available
Supporting Statement - 0110.docx	Supporting Statement A	Uploaded 2020-08-24	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9081	State Mental Institution Policy Review	Form	Modified	State Mental Instintution Policy Review
9081	State Mental Institution Policy Review	Other-Revised PA & PRA Statements	Modified

ICR Details

OMB Control No: 0960-0110	ICR Reference No: 202004-0960-007
Status: Active	Previous ICR Reference No: 201701-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: State Mental Institution Policy Review
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/19/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/24/2020
Terms of Clearance: In accordance with 5 CFR 1320, this information collection is approved.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2026	36 Months From Approved	11/30/2024
Responses	68	0	69
Time Burden (Hours)	68	0	69
Cost Burden (Dollars)	0	0	0

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Abstract: SSA makes annual grants to the Protection and Advocacy Agencies (P&A) in each state to conduct, for SSA, all representative payee reviews. The collection of this information is mandatory for the completion of onsite reviews of State mental institutions. The P&As use Form SSA-9584-BK to collect information during State mental institutions onsite reviews. The P&As use the SSA-9584-BK to: (1) to determine if the policies and practices of a State mental institution acting as a representative payee for SSA beneficiaries conform to SSA’s regulations in the use of benefits; (2) to confirm that institutions are performing other duties and responsibilities required of representative payees; and (3) as the basis for conducting onsite reviews of the Institutions and preparing subsequent reports of findings. The respondents are State mental institutions serving as representative payees for Social Security beneficiaries and Supplemental Security Income (SSI) recipients.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: The Public Health and Welfare
   US Code: 42 USC 1383 Name of Law: The Public Health and Welfare
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 26776	05/05/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 50862	08/18/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
State Mental Institution Policy Review	SSA-9584-BK	State Mental Instintution Policy Review

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	68	69	0	0	-1	0
Annual Time Burden (Hours)	68	69	0	0	-1	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The decrease in burden hours stems from a decline in the number of State institutions participating in the onsite review program. As of December 2020, there are approximately 203 State institutions participating in the onsite review program. SSA reviews institutions triennially, reviewing one-third (68) of the 203 participating institutions each year.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/24/2020

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