Request for Workers' Compensation/Public Disability Benefit Information

Forms and Documents

Document	Type	Status	Availability
Form SSA-1709 Request for Worker's Compensation/Public Disability Benefit Information	Form	Modified	Available
Form SSA-1709 SSA-1709	Form	Modified	Available
Addendum - 0098 (Final).docx	Supplementary Document	Uploaded 2021-09-02	Available
Addendum - 0098 (Final).docx	Supplementary Document	Uploaded 2021-09-02	Repair queued
Supporting Statement - 0098 (Final).docx	Supporting Statement A	Uploaded 2024-07-23	Available
Supporting Statement - 0098 (Final).docx	Supporting Statement A	Uploaded 2021-09-03	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
43695	SSA-1709	Form	Modified	Request for Worker's Compensation/Public Disability Benefit Information
43695	SSA-1709	Form	Modified
43695	SSA-1709	Other-Revised PA and PRA Statements	Modified

ICR Details

OMB Control No: 0960-0098	ICR Reference No: 202104-0960-009
Status: Active	Previous ICR Reference No: 201802-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Workers' Compensation/Public Disability Benefit Information
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: 08/12/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/03/2021
Terms of Clearance: The agency made minor modifications to the Supporting Statement A to clarify the operation of the collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2027	36 Months From Approved	08/31/2024
Responses	120,000	0	120,000
Time Burden (Hours)	30,000	0	30,000
Cost Burden (Dollars)	0	0	0

---

Abstract: Claimants for Social Security disability payments who are also receiving WC/PDB must notify SSA about their WC/PDB, so the agency can consider a possible offset to reduce their Social Security disability payments accordingly. If claimants provide necessary evidence, such as a copy of their award notice, benefit check, etc. that is sufficient verification. In cases where claimants cannot provide such evidence, SSA uses Form SSA-1709 to obtain WC/PDB payment evidence. The entity paying the WC/PDB benefits, its agent (such as insurance carrier), or an administrating public agency completes this form. The respondents are Federal, State, and local agencies; insurance carriers; and public or private self-insured companies administering WC/PDB benefits to disability claimants.

---

Authorizing Statute(s): US Code: 42 USC 424a Name of Law: The 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:
	86 FR 29348	06/01/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 49403	09/02/2021
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
SSA-1709	SSA-1709	Request for Worker's Compensation/Public Disability Benefit Information

---

ICR Summary 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	120,000	120,000	0	0	0	0
Annual Time Burden (Hours)	30,000	30,000	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: $600,000

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: 09/03/2021

---