Information Collection Request

The Ticket to Work and Self-Sufficiency Program

ICR 202403-0960-004 · OMB 0960-0644 · Active

Forms and Documents

Document	Type	Status	Availability
Form SSA-1370 a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a); 411.465- Individualized Work Plan - SSA-1370	Form and Instruction	Unchanged	Repair queued
Form SSA-1370 a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a); 411.465- Individualized Work Plan - SSA-1370	Form and Instruction	Unchanged	Repair queued
Form SSA-1401 f) 20 CFR 411.560 - SSA-1401, Split Payment Situations	Form	Modified	Repair queued
Form SSA-1401 f) 20 CFR 411.560 - SSA-1401, Split Payment Situations	Form	Modified	Repair queued
Form SSA-1394 i) 20 CFR 411.320 - SSA-1374, EN Contract Changes	Form and Instruction	Unchanged	Repair queued
Form SSA-1394 i) 20 CFR 411.320 - SSA-1374, EN Contract Changes	Form and Instruction	Unchanged	Repair queued
Form SSA-1391 f) 20 CFR 411.575 - Requesting EN Payments - SSA-1391; SSA-1398	Form and Instruction	Modified	Available
Form SSA-1391 f) 20 CFR 411.575 - Requesting EN Payments - SSA-1391; SSA-1398	Form and Instruction	Modified	Repair queued
Form SSA-1375 c) 20 CFR 411.200(b) - SSA-1375	Form	Unchanged	Available
Form SSA-1375 c) 20 CFR 411.200(b) - SSA-1375	Form	Unchanged	Missing upstream
Justification for a Non-Substantive Changes for 0960-0644.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-04-08	Available
Justification for a Non-Substantive Changes for 0960-0644.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-04-08	Repair queued
Supporting Statement - 0644 (Final).docx	Supporting Statement A	Uploaded 2022-02-28	Available
Supporting Statement - 0644 (Final).docx	Supporting Statement A	Uploaded 2022-02-28	Repair queued

IC Document Collections

IC ID	Collection	Type	Status
9680	a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a); 411.465- Individualized Work Plan - SSA-1370	Form and Instruction	Unchanged
9680	a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a); 411.465- Individualized Work Plan - SSA-1370	Form and Instruction	Unchanged
251498	j) 20 CFR 411.200(b) - WISE Webinar Survey	Other-Wise Survey	Unchanged
251497	g) 20 CFR 411.325 (f)- Annual Performance	Other-Annual Performance Outcome Report	Unchanged
251496	g) 20 CFR 411.325 (f)- Certification of Services		Unchanged
208203	j) 20 CFR 411.200(b) WISE Webinar Registration Page	Other-online registration form	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
201837	a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1365 State Agency Ticket Assignment Form	Other-screens	Unchanged
190323	f) 20 CFR 411.560 - SSA-1401, Split Payment Situations	Form	Modified
190323	f) 20 CFR 411.560 - SSA-1401, Split Payment Situations	Form	Modified
190204	i) 20 CFR 411.320 - SSA-1374, EN Contract Changes	Form and Instruction	Unchanged
190204	i) 20 CFR 411.320 - SSA-1374, 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) - Proof of Relationship	Instruction	Unchanged
184462	f) 20 CFR 411.575 - Requesting EN Payments - SSA-1391; SSA-1398	Form and Instruction	Modified
184462	f) 20 CFR 411.575 - Requesting EN Payments - SSA-1391; SSA-1398	Form and Instruction	Modified
184461	e) 20 CFR 411.400-411.420, 411.325(d), 411.415 - Reporting Referral Agreement		Unchanged
184460	d) 20 CFR 411.505 - Selecting a Payment System		Unchanged
184457	c) 20 CFR 411.200(b) - SSA-1375	Form	Unchanged
184457	c) 20 CFR 411.200(b) - SSA-1375	Form	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

Status	Active
Agency/Subagency	SSA
OMB Control No	0960-0644
Type of Information Collection	No material or nonsubstantive change to a currently approved collection
Previous ICR Reference No	202401-0960-002
Date Submitted to OIRA	2024-04-08
Requested Expiration Date	1969-12-31