Employee Work Activity Questionnaire

Forms and Documents

Document Name	Status
Form SSA-3033 Employee Work Activity Questionnaire Form and Instruction	Modified
Addendum - 0483.docx Supplementary Document	2020-08-25
Supporting Statement - 0483.docx Supporting Statement A	2020-08-25

IC Document Collections

IC ID	Document Title	Status
9380	Employee Work Activity Questionnaire Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0483	ICR Reference No: 202004-0960-009
Status: Received in OIRA	Previous ICR Reference No: 201612-0960-008
Agency/Subagency: SSA	Agency Tracking No:
Title: Employee Work Activity Questionnaire
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/25/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2021
Responses	15,000	15,000
Time Burden (Hours)	3,750	3,750
Cost Burden (Dollars)	0	0

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Abstract: SSDI beneficiaries and SSI recipients qualify for payments when a physical or mental impairment prevents them from performing SGA. When disability beneficiaries attempt to return to work after receiving payments, but are unable to continue working or have subsidized work, SSA contacts the employer by using Form SSA 3033, Employee Work Activity Questionnaire. SSA uses this form to contact the employer of the applicant or beneficiary to validate their allegation of unsuccessful work attempts and subsidies. The evidence provided by the employer on the SSA-3033 is used to determine whether the beneficiary is eligible for disability payments. The collection of this information is voluntary; however, failure to submit the information may result in non-entitlement to benefits. SSA employees may assist the employer in completing the form via the telephone, or the form may be mailed to the employer to complete. SSA uses this form for both initial claims and post-entitlement reviews. The respondents are employers of SSDI beneficiaries and SSI recipients who unsuccessfully attempted to return to work.

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Authorizing Statute(s): US Code: 42 USC 421 Name of Law: Social Security Act
   US Code: 42 USC 1382a Name of Law: Social Security Act
   US Code: 42 USC 1382c Name of Law: Social Security Act
   US Code: 42 USC 423 Name of Law: Social Security Act
  

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 34703	06/05/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 51540	08/20/2020
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Employee Work Activity Questionnaire	SSA-3033	Work Activity Questionnaire

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ICR Summary of Burden

	Total Request	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	15,000	15,000	0	0	0	0
Annual Time Burden (Hours)	3,750	3,750	0	0	0	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:

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Annual Cost to Federal Government: $142,250

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: 08/25/2020

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