Site Review Questionnaires for Volume and Fee-for-Service Payees and Beneficiary Interview Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-637 Expanded Monitoring Site Review Questionnaire for Volume and Fee for Service Payees	Form	Modified	Available
Form SSA-637 Site Review Questionnaires for Volume and Fee-for-Service Payees	Form	Modified	Repair queued
Form SSA-639 Expanded Monitoring Site Review Beneficiary Review Form	Form	Modified	Available
Form SSA-639 Expanded Monitoring Site Review: Beneficiary Interview Form	Form	Modified	Repair queued
Supporting Statement - 0960-0633 (final).docx	Supporting Statement A	Uploaded 2023-10-16	Available
Supporting Statement - 0633 (Final).docx	Supporting Statement A	Uploaded 2022-01-11	Repair queued
Addendum - 0633 (Final).docx	Supplementary Document	Uploaded 2022-01-11	Available
Addendum - 0633 (Final).docx	Supplementary Document	Uploaded 2022-01-11	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
38057	Site Review Questionnaires for Volume and Fee-for-Service Payees	Form	Modified	Expanded Monitoring Site Review Questionnaire for Volume and Fee for Service Payees
38057	Site Review Questionnaires for Volume and Fee-for-Service Payees	Form	Modified
38057	Site Review Questionnaires for Volume and Fee-for-Service Payees	Other-Revised PA & PRA Statements	Modified
178591	Expanded Monitoring Site Review: Beneficiary Interview Form	Form	Modified	Expanded Monitoring Site Review Beneficiary Review Form
178591	Expanded Monitoring Site Review: Beneficiary Interview Form	Form	Modified
178591	Expanded Monitoring Site Review: Beneficiary Interview Form	Other-Revised PA & PRA Statements	Modified

ICR Details

OMB Control No: 0960-0633	ICR Reference No: 202108-0960-001
Status: Active	Previous ICR Reference No: 201808-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Site Review Questionnaires for Volume and Fee-for-Service Payees and Beneficiary Interview Form
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: 04/29/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/12/2022
Terms of Clearance: The agency provided clarifying details to the supporting statement.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2027	36 Months From Approved	04/30/2024
Responses	27,000	0	26,696
Time Burden (Hours)	13,667	0	13,477
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the SSA-637, Site Review Questionnaire for Volume and Fee-for-Service Payees, to obtain information from payees about how the organization operates and carries out its representative payee responsibilities, including how it manages beneficiary funds. We then use the SSA-639, Beneficiary Interview Form, to obtain information from the beneficiaries to help corroborate the payee's statements. Due to the sensitivity of the information, SSA employees always complete the forms based on the answers respondents give during the interview. This collection is mandatory for representative payees and voluntary for beneficiaries. SSA will not allow representative payees who do not respond to continue serving as representative payees. The respondents are individuals; State and local governments; non-profit and for profit organizations serving as representative payees; and the beneficiaries they serve.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: The Social Security Act
   US Code: 42 USC 1383 Name of Law: The Social Security Act
   PL: Pub.L. 108 - 203 102(b) Name of Law: The Social Security Protection 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:
	86 FR 56746	10/12/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 139	01/03/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Expanded Monitoring Site Review: Beneficiary Interview Form	SSA-639	Expanded Monitoring Site Review Beneficiary Review Form
Site Review Questionnaires for Volume and Fee-for-Service Payees	SSA-637	Expanded Monitoring Site Review Questionnaire for Volume and Fee for Service Payees

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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	27,000	26,696	0	0	304	0
Annual Time Burden (Hours)	13,667	13,477	0	0	190	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: When we last cleared this IC, the burden was 13,477 hours. However, we are currently reporting a burden of 13,667 hours. This change stems from an increase in the number of responses from 26,696 to 27,000. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data.

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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: 01/12/2022

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