Supporting Statement - 0667

Supporting Statement for

Filing Claims Under the Federal Tort Claims Act

20 C.F.R. Part 429, Subpart 100

OMB No. 0960-0667

1. Justification

1. Introduction/Authoring Laws and Regulations

The Federal Tort Claims Act (FTCA) is the legal mechanism for compensating people injured through negligent or wrongful acts that occur during the performance of official duties by Federal employees. The FTCA, 28 USC 2671‑2680 of the United States Code, authorizes the collection of this information. One can also find authorization in the Code of Federal Regulations, section 20 CFR 429.101-429.110.

2. Description of Collection

The Social Security Administration (SSA) accepts monetary claims filed under the FTCA for damages against the United States; loss of property; personal injury; or death resulting from an SSA employee's wrongful act or omission. The regulation sections cleared under this information collection request that claimants provide information SSA can use to investigate and determine whether to make an award, compromise, or settlement under the FTCA.

In accordance with the law, SSA accepts claims for money damages filed under the FTCA against the United States for the following:

• 20 CFR 429.102-103, Filing a Claim. To file a claim, an individual or entity must complete the Department of Justice’s Standard Form (SF)-95 or submit written notification of the incident accompanied by a claim for money damages in a certain sum for damage to or loss of property caused by the incident.

• 20 CFR 429.104(a), Damage to or loss of property. To claim property damage, the individual or entity may submit the following types of evidence: proof of ownership; itemized statements of the amount claimed; itemized receipt of payment for necessary repairs; statements listing purchase, purchase price, market value, and salvage value; or any other evidence bearing on the responsibility of the United States for the injury to, or loss of, property,

• 20 CFR 429.104(b), Personal injury. To claim personal injury, the individual or entity may submit a written report from a physician explaining the nature and extent of injury; nature and extent of treatment; any degree of temporary or permanent disability; the prognosis; period of hospitalization; any diminished earning capacity; itemized bills for treatment expenses; and a statement of expected duration of, and expenses for, treatment. We may also require the individual to submit a written statement from the individual’s employer showing actual time lost from employment, or, if self-employed, documentary evidence showing the amount of earnings actually lost. The individual may also submit any other evidence bearing on the responsibility of the United States for the personal injury or damages claimed.

• 20 CFR 429.104(c), Death that a negligent or wrongful act or omission an SSA employee caused. To assert that an SSA employee caused a death, the claimant must submit evidence and information such as the following: an authenticated death certificate showing cause of death, date of death, and age at time of death; the employment or occupation at time of death, including the deceased’s monthly or yearly salary or earnings (if any), and the duration of last employment or occupation. We may also require information regarding the deceased’s survivors; the deceased’s general health before death; itemized bills for medical and burial expenses; a physician’s detailed statement specifying the injuries suffered; and the deceased’s physical condition. In addition, the individual may submit any other evidence or information bearing on the responsibility of the United States for the death or damages claimed.

All the above regulatory requirements pertain to the claims individuals or entities submit to SSA along with the appropriate evidence or information pertaining to their claims. For the United States to be liable under the FTCA, the Federal employee must cause the loss, damage, injury or death in the performance of official duties, under circumstances in which the United States, if a private person, would be liable in accordance with the law of the place where the act or omission occurred.

If SSA denies the claim, before filing suit and before the expiration of the 6‑month period after the date of mailing the denial notice, the claimant may take the following action:

• 20 CFR 429.106(b), File a written request with SSA for reconsideration. The individual must send this written request via certified or registered mail.

The respondents are individuals or entities making a claim under the FTCA, which occurs on an as needed basis. SSA employees collect the information voluntarily submitted by FTCA claimants.

3. Use of Information Technology to Collect the Information

SSA collects the information through various means, including written submissions via USPS mail without the use of any form, or submissions using OMB-approved standard form, SF-95 (OMB No. 1105-0008). SSA did not create an electronic form under the agency’s Government Paperwork Elimination Act (GPEA) plan because on average less than 200 respondents complete the form annually, and because respondents can use the Department of Justice’s standard form to submit the information. We do not count the burden for the use of the SF-95 (1105-0008), as the Department of Justice owns the OMB approval for that standard form. Rather, we only count the burden for those respondents who may submit written requests without the use of the standard form under this OMB approval. We have noted the use of the SF-95 on the burden chart in #12 below with a 1‑hour placeholder burden.

4. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it preclude duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequences of Not Collecting Information or Collecting it Less Frequently

If we did not collect this information, SSA would be unable to investigate and determine whether to make an award, compromise, or settlement under the FTCA. Because we only collect the information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to collect this information in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on March 1, 2021, at

86 FR 12068, and we received no public comments. The 30-day FRN published on June 8, 2021 at 86 FR 30511. If we receive any comments in response to this Notice, we will forward them to OMB.

9. Payment or Gifts to Respondents

Other than settlement payments where SSA determines that it is liable for the damages alleged under the FTCA, and where the amount is under $2,500, SSA makes no payments to respondents. SSA does not accept gifts from respondents, nor does SSA give gifts to respondents.

10. Assurances of Confidentiality

SSA protects and holds confidential the information we collect in accordance

42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

11. Justification for Sensitive Questions

The information collection sometimes contains questions or information of a sensitive nature, potentially medical records if necessary, in reference to a FTCA claim. If information of a sensitive nature is necessary, SSA explains to the respondent the clear correlation for the purpose of the information and voluntary submission. Those agency employees who need the information in the scope of their official duties are the only ones who use the information to make decisions in accordance with the law.

12. Estimates of Public Reporting Burden

The following chart shows the public reporting burden for the written requests we receive under the CFR citations we described in #2 above. The citations for 20 CFR 429.102 and 429.103 reference the SF‑95 (OMB No. 1105-0008). We only include a 1-hour placeholder burden for this ICR as this Standard Form is not an SSA form:

Regulation Citations	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollars)**	Total Annual Opportunity Cost (dollars)***
429.102; 429.103*	1	1	1	1	$27.07**	$0***
429.104(a)	11	1	5	1	$27.07**	$27***
429.104(b)	43	1	5	4	$27.07**	$108***
429.104(c)	1	1	5	0	$27.07**	$0***
429.106(b)	8	1	10	1	$27.07**	$27***
Totals	64			7		$162***

* We are including a one-hour placeholder burden for 20 CFR 429.102 and 429.103, as respondents complete OMB-approved Form SF–95, OMB No. 1105–0008. Since the burden for these citations is covered under a separate OMB number, we are not double counting the burden here.

** We based this figure on the average U.S. citizen’s hourly salary, as reported by the U.S. Bureau of Labor Statistics (https://www.bls.gov/oes/current/oes_nat.htm#00-0000).

***This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

The total burden for this ICR is 6 hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $162. SSA does not charge respondents to complete FTCA applications.

13. Cost to Respondents

This collection does not impose a known cost burden to the respondents.

14. Annual Cost to the Federal Government

The Department of Justice supplies the form (SF-95), so we do not account for the cost to the Federal Government for the standard form here.

The annual cost to the Federal Government is approximately $550. This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars*
Designing and Printing the Form	Design Cost + Printing Cost	$0
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$0
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$550
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0
Systems Development, Updating, and Maintenance	GS-9 employee x man hours for development, updating, maintenance	$0
Quantifiable IT Costs	Any additional IT costs	$0
Total		$550

* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have.  We use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection

There are no changes to the public reporting burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Expiration Date

SSA is not requesting an exemption from the requirement to display an expiration date.

18. Exception to Certification Statement

SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

2. Collections of Information Employing Statistical Methods

SSA did not use statistical methods for this information collection.