Expanded Monitoring Site Review: Beneficiary Interview Form

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

Documents and Forms

Document Name Document Type
Form SSA-639 Expanded Monitoring Site Review: Beneficiary Interview Form Form
SSA-639 - Revised PA & PRA Statements.pdf Other-Revised PA & PRA Statements
SSA-639 Expanded Monitoring Site Review Beneficiary Review Form SSA-639 - Revised.pdf Form
SSA-639 - Current.pdf SSA-639 - Current IC Document

Information Collection (IC) Details

IC Title:	Expanded Monitoring Site Review: Beneficiary Interview Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.2035 20 CFR 416.708 20 CFR 404.2065 20 CFR 416.665 20 CFR 416.701

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-639	Expanded Monitoring Site Review Beneficiary Review Form	SSA-639 - Revised.pdf		Yes	Yes	Fillable Printable
Other-Revised PA & PRA Statements			SSA-639 - Revised PA & PRA Statements.pdf		Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 22,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	22,000	228	21,772
Annual IC Time Burden (Hours)	3,667	38	3,629
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-639 - Current	SSA-639 - Current.pdf	01/11/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.