Filing Claims Under the Federal Tort Claims Act

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SF-95 Claim for Damage, Injury, or Death	Form and Instruction	Modified	Available
Form SF-95 20 CFR 429.102; 429.103 - Filing a Claim (SF-95, OMB No. 1105-0008)	Form and Instruction	Modified	Repair queued
Supporting Statement - 0667 (Final).docx	Supporting Statement A	Uploaded 2024-07-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9718	20 CFR 429.102; 429.103 - Filing a Claim (SF-95, OMB No. 1105-0008)	Form and Instruction	Modified	Claim for Damage, Injury, or Death
9718	20 CFR 429.102; 429.103 - Filing a Claim (SF-95, OMB No. 1105-0008)	Form and Instruction	Modified
187062	20 CFR 429.106(b) - File a written request with SSA for reconsideration		Modified
187061	20 CFR 429.104(c) - Death that a negligent or wrongful act or omission an SSA employee caused		Modified
187060	20 CFR 429.104(b) - Personal injury		Modified
187016	20 CFR 429.104(a) - Damage to or loss of property		Modified

ICR Details

OMB Control No: 0960-0667	ICR Reference No: 202403-0960-011
Status: Active	Previous ICR Reference No: 202104-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Filing Claims Under the Federal Tort Claims Act
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/05/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/08/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2027	36 Months From Approved	09/30/2024
Responses	41	0	64
Time Burden (Hours)	41	0	64
Cost Burden (Dollars)	0	0	0

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Abstract: The Federal Tort Claims Act (FTCA) is the mechanism for compensating people who Federal employees injured through negligent or wrongful acts that occurred during the performance of those employees’ official duties. SSA accepts 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 various types of claims included under this information collection request require claimants to provide information SSA can use to determine whether to make an award, compromise, or settlement under the FTCA. The respondents are individuals or entities making a claim under the FTCA.

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Authorizing Statute(s): US Code: 28 USC 2671-2680 Name of Law: Federal Tort Claims 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:
	89 FR 24886	04/09/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 55666	07/05/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
20 CFR 429.102; 429.103 - Filing a Claim (SF-95, OMB No. 1105-0008)	SF-95	Claim for Damage, Injury, or Death
20 CFR 429.104(a) - Damage to or loss of property
20 CFR 429.104(b) - Personal injury
20 CFR 429.104(c) - Death that a negligent or wrongful act or omission an SSA employee caused
20 CFR 429.106(b) - File a written request with SSA for reconsideration

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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	41	64	0	0	-23	0
Annual Time Burden (Hours)	41	64	0	0	-23	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 in 2021, the burden was 64 hours. However, we are currently reporting a burden of 41 hours. This stems from a minor decrease in respondents choosing to respond via written statement instead of using the SF-95 (OMB No. 1105 0008). 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: $550

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.     No

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: 07/08/2024

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