The Ticket to Work and Self-Sufficiency Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-1370 Ticket to Work Individual Work Plan	Form and Instruction	Unchanged	Repair queued
Form SSA-1370 a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370	Form and Instruction	Unchanged	Repair queued
Form SSA-1365 State Agency Ticket Assignment Form	Form	Unchanged	Available
Form SSA-1365 State Agency Ticket Assignment Form (SSA-1365)	Form	Unchanged	Repair queued
Form SSA-1401 Employment Network Split Payment Request Form	Form	Unchanged	Available
Form SSA-1401 f) 20 CFR 411.560 - SSA-1401, Split Payment Situations	Form	Unchanged	Repair queued
Form SSA-1394 Employment Network Contract Change Form	Form and Instruction	Unchanged	Available
Form SSA-1394 i) 20 CFR 411.320 - SSA-1394, EN Contract Changes	Form and Instruction	Unchanged	Repair queued
Form SSA-1389 EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request)	Form and Instruction	Modified	Available
Form SSA-1391 Employment Network Payment Request Form	Form and Instruction	Modified	Available
Form SSA-1375 Ticket to Work Progress Review Form	Form	Unchanged	Available
Form SSA-1375 c) 20 CFR 411.200(b) - SSA-1375	Form	Unchanged	Repair queued
Justification for the Non-Substantive Changes - 0644.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-01-15	Repair queued
Supporting Statement - 0644.docx	Supporting Statement A	Uploaded 2019-01-18	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9680	a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370	Form and Instruction	Unchanged	Ticket to Work Individual Work Plan
9680	a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370	Form and Instruction	Unchanged
218037	Ticket Portal	Other-TTW Portal Screens	Unchanged
218036	State Agency Ticket Assignment Form (SSA-1365)	Form	Unchanged	State Agency Ticket Assignment Form
218036	State Agency Ticket Assignment Form (SSA-1365)	Form	Unchanged
218036	State Agency Ticket Assignment Form (SSA-1365)	Other-Revised PA and PRA Statements	Unchanged
208203	20 CFR 411.200(b) WISE Webinar Registration Page	Other-online registration form	Unchanged
203490	i) 20 CFR 411.320 - EN Contract Changes, Portal	Other-Internet Screens	Unchanged
201989	a) 20 CFR 411.140(d)(2) - Ticket Assignability - Portal	Other-Internet Screens	Unchanged
201988	a) 20 CFR 411.140(d)(2) - Ticket Assignability - IVR Automated Telephone		Unchanged
201842	f) 20 CFR 411.575 - Portal Screens (SSA-1391 et al)		Unchanged
201841	c) 20 CFR 411.200(b) - Request for Certification of Work Portal Screens	Other-Internet Screens	Unchanged
201838	b) 20 CFR 411.145; 411.325 - Unassignments Portal Screens	Other-screens	Unchanged
201837	a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370 Portal Screens	Other-screens	Unchanged
190323	f) 20 CFR 411.560 - SSA-1401, Split Payment Situations	Form	Unchanged	Employment Network Split Payment Request Form
190323	f) 20 CFR 411.560 - SSA-1401, Split Payment Situations	Form	Unchanged
190323	f) 20 CFR 411.560 - SSA-1401, Split Payment Situations	Other-Revised PA and PRA Statements	Unchanged
190204	i) 20 CFR 411.320 - SSA-1394, EN Contract Changes	Form and Instruction	Unchanged	Employment Network Contract Change Form
190204	i) 20 CFR 411.320 - SSA-1394, EN Contract Changes	Form and Instruction	Unchanged
184464	h) 20 CFR 411.435, 411.615, 411.625 - Dispute Resolutions		Unchanged
184463	g) 20 CFR 411.325(f) - Periodic Outcomes Reporting	Instruction	Unchanged
184462	f) 20 CFR 411.575 - SSA-1391; SSA-1389	Form and Instruction	Modified	EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request)
184462	f) 20 CFR 411.575 - SSA-1391; SSA-1389	Form and Instruction	Modified	Employment Network Payment Request Form
184462	f) 20 CFR 411.575 - SSA-1391; SSA-1389	Other-Revised PA and PRA Statements	Modified
184461	e) 20 CFR 411.325(d), 411.415 - Reporting Referral Agreement		Unchanged
184460	d) 20 CFR 411.365, 411.505, 411.515 - Selecting a Payment System		Unchanged
184459	c) 20 CFR 411.210(b) -Ticket-Use Status after Not Making Timely Progress		Unchanged
184457	c) 20 CFR 411.200(b) - SSA-1375	Form	Unchanged	Ticket to Work Progress Review Form
184457	c) 20 CFR 411.200(b) - SSA-1375	Form	Unchanged
184456	c) 20 CFR 411.192(b)&(c) - Request to Place Ticket in Inactive Status		Unchanged
184450	b) 20 CFR 411.535(a)(1)(iii) - VR Case Closures		Unchanged
184449	b) 20 CFR 411.145 & 411.325 - Requesting Ticket Unassignments	Other-screens	Unchanged
184447	a) 20 CFR 411.166; 411.170(b) - Elecronic Data Sharing	Other-screens	Unchanged

ICR Details

OMB Control No: 0960-0644	ICR Reference No: 202101-0960-002
Status: Historical Active	Previous ICR Reference No: 201809-0960-003
Agency/Subagency: SSA	Agency Tracking No:
Title: The Ticket to Work and Self-Sufficiency Program
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/16/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/15/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2022	03/31/2022	03/31/2022
Responses	359,406	0	359,406
Time Burden (Hours)	84,440	0	84,440
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA’s Ticket to Work (TTW) Program transitions Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) recipients toward independence by allowing them to receive Social Security payments while maintaining employment under the auspices of the program. SSA uses service providers, called Employment Networks (ENs), to supervise participant progress through the stages of TTW Program participation, such as job searches and interviews; progress reviews; and changes in ticket status. ENs can be private for-profit and nonprofit organizations, as well as state vocational rehabilitation agencies (VRs). SSA and the ENs utilize the TTW program manager to operate the TTW Program and exchange information about participants. For example, the ENs use the program manager to provide updates on tasks such as selecting a payment system, or requesting payments for helping the beneficiary achieve certain work goals. Since the ENs are not PRA-exempt, the multiple information collections within the TTW program manager require OMB approval. Most of the categories of information are necessary for SSA to: (1) comply with the Ticket to Work legislation; and (2) provide proper oversight of the program. SSA collects this information through several modalities, including forms, electronic exchanges, and written documentation. The respondents are the ENs or state VRs, SSDI beneficiaries, and blind or disabled SSI recipients working under the auspices of the TTW Program. We are removing two ICs from this ICR, as we no longer use them to collect information, as we no longer require the information they collect.

---

Authorizing Statute(s): US Code: 42 USC 1320b¿19 Name of Law: Social Security Act
   US Code: 42 USC 405 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 53352	10/22/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 66330	12/26/2018
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 24

table that charts list of burden

IC Title	Form No.	Form Name
20 CFR 411.200(b) WISE Webinar Registration Page
State Agency Ticket Assignment Form (SSA-1365)	SSA-1365	State Agency Ticket Assignment Form
Ticket Portal
a) 20 CFR 411.140(d)(2) - Ticket Assignability - IVR Automated Telephone
a) 20 CFR 411.140(d)(2) - Ticket Assignability - Portal
a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370	SSA-1370	Ticket to Work Individual Work Plan
a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370 Portal Screens
a) 20 CFR 411.166; 411.170(b) - Elecronic Data Sharing
b) 20 CFR 411.145 & 411.325 - Requesting Ticket Unassignments
b) 20 CFR 411.145; 411.325 - Unassignments Portal Screens
b) 20 CFR 411.535(a)(1)(iii) - VR Case Closures
c) 20 CFR 411.192(b)&(c) - Request to Place Ticket in Inactive Status
c) 20 CFR 411.200(b) - Request for Certification of Work Portal Screens
c) 20 CFR 411.200(b) - SSA-1375	SSA-1375	Ticket to Work Progress Review Form
c) 20 CFR 411.210(b) -Ticket-Use Status after Not Making Timely Progress
d) 20 CFR 411.365, 411.505, 411.515 - Selecting a Payment System
e) 20 CFR 411.325(d), 411.415 - Reporting Referral Agreement
f) 20 CFR 411.560 - SSA-1401, Split Payment Situations	SSA-1401	Employment Network Split Payment Request Form
f) 20 CFR 411.575 - Portal Screens (SSA-1391 et al)
f) 20 CFR 411.575 - SSA-1391; SSA-1389	SSA-1391, SSA-1389	Employment Network Payment Request Form ,   EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request)
g) 20 CFR 411.325(f) - Periodic Outcomes Reporting
h) 20 CFR 411.435, 411.615, 411.625 - Dispute Resolutions
i) 20 CFR 411.320 - EN Contract Changes, Portal
i) 20 CFR 411.320 - SSA-1394, EN Contract Changes	SSA-1394	Employment Network Contract Change Form

---

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	359,406	359,406	0	0	0	0
Annual Time Burden (Hours)	84,440	84,440	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:

---

Annual Cost to Federal Government: $7,000,000

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

---

Common Form ICR:  No

---

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: 01/15/2021

---