Addendum to the Supporting Statement for 0960-0059

Addendum to the Supporting Statement for Form SSA-821-BK

Work Activity Report – Employee

20 CFR 404.1520(b), 404.1571-404.1576,

404.1584-404.1593, and 416.971-416.976

OMB No. 0960-0059

Revisions to the Collection Instrument:

• Change #1: One Page 1, we are right aligning the header information, and left aligning the notice specific information (FO, Date, BNC, Address).

Justification #1: We are revising the formatting because of new and upcoming methods of distribution including eWCDR (new work CDR development tool) and the use of central print.

• Change #2: On Page 1, we are revising the language of the opening paragraph to the cover letter:

  • Current language: “We are writing to you because we believe you may have recent work activity and we need to know more about this work activity. Please tell us about your work since __________________. If you are applying for disability benefits, the information you provide will help us decide if you can receive benefits. If you are currently receiving disability benefits, the information you provide helps us decide if you can continue to receive benefits.”

• Revised Language: One of Social Security’s highest priorities is to support the efforts of beneficiaries with disabilities who want to work. The Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) programs include several employment support provisions commonly referred to as work incentives, or special rules that help you to receive, or continue to receive benefits even if you are working. We need more information to see if any of these incentives apply to you. If you are just now applying for disability benefits, the information you give us helps us decided if you can receive benefits. If you are currently receiving disability benefits, the information you give us help us decide if your benefits can continue.

The information we ask for includes:

• Employment History – This includes your dates of employment, wages or salary earned, and any special pay you received (e.g., sick and vacation pay, disability pay from your employer, and workers’ compensation, etc.).

• Special Employment Conditions – If you receive more supervision than other workers doing the same job, have fewer or simpler tasks to complete, are given additional or longer breaks, or have a job coach/mentor who performs some of your work tasks, you may be working under special conditions. We may need to contact your employer to verify your special work conditions.

• Work Expenses related to your disability – If you work and have a disability, you may need certain items or services to assist you (e.g., co-pays for prescription drugs, medical device expenses, special transportation, counseling fees, expenses related to a service animal, etc.)

We may ask for proof of any of the information you provide.

Justification #2: We are making these revisions to comply with the requirements for gender neutral language. We are also softening and simplifying the language. We also clarified the language and provided information to the beneficiary regarding the types of information we are asking for, why we need the information, how we will use it, and provided a definition of work incentives.

• Change #3: On Page 1, we revised the language in “What You Need to Do” as follows:

• Current Language: “Please complete and return the completed form within 15 days to the address shown above. It is important to fill out the form carefully and completely. Remember to sign and date the form. If you do not return this form, we may contact your employer or make our determination based on the evidence we have in our records.”

• Revised Language: “Please complete and return this form within 15 days. It is important to fill out the form carefully and completely even if you receive additional forms requesting authorization to obtain wage and employment information from payroll data providers. If you do not return this form, we may contact your employer or make our decision based on the information we have in our records.”

Justification #3: We are revising the language to clarify that the information on this form is needed in addition to another document (SSA-8240) that is now commonly accompanying this form.

• Change #4: On Page 1, we removed the ‘Some Information To Help You Complete This Form’ paragraph.

Justification #4: Historically, we prefilled this section with yearly income information received from the IRS. With information now available through multiple sources, including the anticipation of the Payroll Information Exchange, OMB 0960-0807, MyWageReport, OMB 0960-0715, etc., we typically have access to more recent earnings information. We can display this information in the “Employment Information” Section when we prefill the form. When using a form submitted electronically such as Upload Documents (eSubmit), OMB No. 0960-0830, we cannot prefill any information in the form or include PII prior to sending it to the intended recipient. However, it would cause confusion if left blank; therefore, we are removing it.

• Change #5: On Page 1, we revised the language in the “For More Information” paragraph:

• Current Language: “Please read the enclosed pamphlet, “Working While Disabled: How We Can Help.” It will tell you more about why we need to know about your work and will explain our rules about working. This pamphlet is also available at https://www.ssa.gov/pubs/EN-05-10095.pdf online.”

• Revised Language: “Please read the pamphlet “Working While Disabled: How We Can Help.” It will tell you more about why we need to know about your work and will explain our rules about working. This pamphlet is available online at www.ssa.gov/pubs/EN-05-10095.pdf. You may also visit www.choosework.ssa.gov or contact the Ticket to Work Help Line at 1-866-968-7842 (TTY 1-866-833-2967) to learn more about work incentives and find service providers who can explain how work can affect your benefits.”

Justification #5: We no longer enclose the pamphlet, so we are removing the reference to it. Also, we believe that providing additional links for information on wage reporting and work incentives will help the respondent.

• Change #6: On Page 2, we revised the language in the “If You Have Questions” paragraph:

• Current Language:

If You Have Questions

If you have any questions, or need help completing the form:

• Visit our website at www.ssa.gov to find general information about Social Security.

• Call us toll-free at 1-800-772-1213 or call your local office at _____. You may also call your Social Security contact, at _____. We can answer most questions over the phone.

• Write or visit any Social Security office. If you plan to visit an office, you may call ahead to make an appointment. The office that serves your area is located at: ______.

• If you are deaf or hard of hearing, our toll-free TTY number is 1-800-325-0778.

• If you are outside the United States or its territories: If you are in Canada, visit www.ssa.gov/foreign/canada.htm to find the office that services your area.

• Contact your nearest Federal Benefits Unit (FBU). Visit www.ssa.gov/foreign/foreign.htm for a list of FBU's.

• Write to the Social Security Administration at: P.O. Box 17769 Baltimore, Maryland, 21235-7769 USA

Please have this letter with you if you call or visit an office. If you write, please include a copy of this letter. It will help us answer your questions.

• Revised Language:

Need More Help

If you have any questions, or need help completing the form:

1. Visit www.ssa.gov for fast, simple, and secure online service.

2. Call us at 1-800-772-1213, weekdays from 8:00 am to 7:00 pm. If you are deaf or hard of hearing, call TTY 1-800-325-0778. Please mention this letter when you call.

3. You may also call the office working on your case at .

How are we doing? Go to www.ssa.gov/feedback to tell us.

Justification #6: We revised this language per the approved SSA referral language decision memo for notice alignment.

• Change #7: On Page 2, we removed the referenced to the SSA Pub No. 05-10095 from the Enclosures section.

Justification #7: We no longer enclose the pamphlet and are removing the reference to it. Also, we believe that providing additional links for information on wage reporting and work incentives will help the respondent.

• Change #8: On Page 3, we removed the words “To Be Completed by SSA” from this section.

Justification #8: Depending on how the respondent chooses to submit the information (through the paper form, a personal interview, or the Upload Documents (eSubmit), OMB No. 0960-0830, Portal, it affects who will need to complete the information in that section (the name of the Claimant or Beneficiary, #BNC or SSN, and Blind indicator). Since the claimant or beneficiary may need to complete this section, we removed this instruction.

• Change #9: On Page 3, we added “If a date is not shown, please provide information for the last two years.”

Justification #9: The date can no longer be prefilled, as the respondent may need to fill it out depending upon how they submit the form. Therefore, we added this language and referenced it when applicable throughout the form to simplify form instructions, conform with new production, delivery, and receipt systems, and make the form easier to complete and less intimidating for the claimant or beneficiary.

• Change #10: On Page 3, we removed “To Be Completed By Person Applying for Or Receiving Benefits.” We also changed the title of this Section to “Income Information” from “Information.”

Justification #10: It is not necessary to distinguish who is completing this section because of Change #8. To make the form easier to understand, we added Section Titles such as “Income Information” to the form.

• Change #11: On Page 3, we changed Question 1 from “Have you had any employment income or wages since the DATE shown above in the Identification Section” to “Have you had any employment income or wages since your disability began, since the date shown in the identification section or since we last reviewed your work activity.”

Justification #11: See Change 9. We are not always providing a date, so we revised the language in this question to clarify the date of when we want the information.

• Change #12: On Page 3, we removed the table of income types from Question 2. We changed the language for Question 2 to accommodate the removal of the table. We added NO and YES check boxes to Question 2 for the new language, horizontal check box indicators for possible income types for improved flow, and space to include more information or specify ‘Other’ income type.

Justification 12: Internal and external reviews of the form indicated this section as a pain point for the form. Reports showed that some individuals do not understand why, or in some instances, what we are asking. To address this pain point, we made the form less intimidating, simplified the completion of the form, and provided better instruction and rationale for why SSA needs this information from the individual completing the form.

• Change #13: On Page 3, we added the Section Title “Employment Information.”

Justification #13: To make the form easier to understand, we added Section Titles to the form. Internal and External reviews of the existing form indicated inability to understand the form as a pain point. This change addresses that pain point.

• Change #14: On Page 3, we changed the language in Question 3A to “Beginning with your most recent employer, please tell us about your work activity since the date shown in the IDENTIFICATION section, the date your disability began, since your last work review or within the last two years. If we have not already received proof of income from your employer(s), we may ask you to submit it.”.

Justification #14: See Change and Justification 9: “The date can no longer be prefilled, as the respondent may need to fill it out depending upon how they submit the form. Therefore, we added this language and referenced it when applicable throughout the form to simplify form instructions, conform with new production, delivery, and receipt systems, and make the form easier to complete and less intimidating for the claimant or beneficiary.”

• Change #15: On Pages 4, 5, and 11, we revised the language in the table in which the beneficiary/claimant provides employment information. Everywhere in the form where this information table exists, we made identical changes. We removed “Current or Most Recent” and “Previous,” added “Employer Fax # (include area code), removed “Type of Work,” separated “Date Work Ended (if ended) and “Still Working” into two entry boxes, added “Reason Work Ended (if applicable)” and provided check box choices of “Because of my disability, and Other reason(s).”

Justification #15: Based on internal reviews and discussions with regional Subject Matter Experts, the additional collection of a fax number and the Reason Work Ended for EACH employer would significantly assist with the development of work issue CDR’s. We determined redundancy based on the wording of Question 3A, indicating Current or Most Recent and Previous. We determined redundancy in collecting both “Job Title” and “Type of Work.”

• Change #16: On Page 3, 4, and 9, we removed the ‘Pay Stub Table’ from each employment information iteration and added a check box indicating “I am enlcosing or have already provided pay stub information (online, by mail, or in the office), or it has already been submitted for me.”

Justification #16: We now have various sources to obtain information from the beneficiary regarding wages, such as MyWageReport, OMB 0960-0715, and payroll data from Equifax, a third-party payroll data provider. Often, we already have some wage information for the beneficiary. Completing the ‘Pay Stub Table’ with estimates is error prone and a pain point for the individual completing the form. Based on questionnaires and external reviews, many beneficiaries who complete the form skip this section or stop completing the form altogether when they reach this section. This section can be time consuming and redundant.

• Change #17: On Page 4, we added Question 3C. The table mimics the tables in 3A and 3B.

Justification #17: The new shorter format provided room for another employer in the body of the form.

• Change #18: On Page 4, we changed the language from “If you have more employers, go to Additional Employment Information” to “If you need to tell us about more employers, use the “ADDITIONAL EMPLOYMENT INFORMATION” page at the end of this form.”

Justification #18: We revised the language to provide clearer instruction.

• Change #19: On Page 4, we revised the language for Question 4 and changed the positioning of the check boxes.

• Current Language: “Do you or did you get any other payment(s) or benefit(s) from an employer in addition to the regular pay shown in Question 3?”

• Revised Language: “We only count income directly related to your work. For example, if you are working, but also received income for time off, like sick or vacation pay, we will deduct that income from your total (gross) earnings before we decide if you are eligible for benefits. Or, when you work and receive other types of income, like tips or bonuses, we may add that pay to your total (gross) income before we decide if you are eligible for benefits.

If you worked, did you also get any other income from any employer(s) that you told us about in the EMPLOYMENT INFORMATION section (including the ADDITIONAL EMPLOYMENT INFORMATION page)?”

Justification #19: External reviewers and subject matter experts identified this section as a pain point. Many do not understand why we are asking for this information and find this section overwhelming. Adding the example and explanation for why we are asking for this information makes the form easier to understand. The horizontal positioning of the check boxes improves the flow of the form, makes it less intimidating and reduces the amount of time it takes to complete the form.

• Change #20: On Page 4, we added “If you did not receive any other payments in addition to earnings from work, go to the WORK INCENTIVES section” after the ‘NO’ checkbox.

Justification #20: We added the language to clarify and distinguish this question from Question 2, a pain point identified through internal and external reviews.

• Change #21: On Page 4, we changed the language after the ‘YES’ checkbox to “Mark below any that apply, then go to the WORK INCENTIVES section.”

Justification #21: We changed the language to clarify and to distinguish this question from Question 2, a pain point identified through internal and external reviews.

• Change #22: On Page 4, we changed the positioning of the check boxes and removed “Transportation,” “Car or Vehicle,” “Childcare,” “Meals,” and “Room or Rent” check boxes.

Justification #22: The horizontal positioning of the check boxes improves the flow of the form, makes it less intimidating and reduces the amount of time it takes to complete the form. Removal of above income types will reduce the burden on the claimant/beneficiary and the psychological cost of the form. Based on internal review, these are rarely used as types of income and often cause confusion. The existence of the ‘Other’ choice and the instruction within the question to “Please explain below” allow the beneficiary to indicate any of the lesser used types of non-wage income.

• Change #23: On Page 4, we added a “Workers’ Comp” check box.

Justification #23: We made this change in response to an Audit recommendation. The agency often misses development of workers’ comp claims and the Audit identified SSA-821 as a source that could be used as a lead for this information. This choice is new, although it existed in Question 2. If the individual is not working, they are directed to “Go to Question 3,” thereby skipping Question 2 and the opportunity to tell us about Workers’ Comp (WC). We will gather the WC lead in either or both places after this change.

• Change #24: On Page 4, we replaced the information gathering table currently used to explain what types of income are checked, if any, with space to include more information or specify ‘Other’ income type.

Justification #24: We replaced the table to reduce the burden on the claimant/beneficiary and the psychological cost of the form. It takes less time for the claimant to complete the form and the claimant will not have to navigate back and forth to a general remarks section. We may not need to verify the information (i.e., the individual is not working at SGA level). If the technician needs to verify an allegation, marking the provided check box will act as a lead for this development.

• Change #25: On Page 6, we added Section Title “Work Incentive Information” and a lead paragraph explaining the definition of work incentives and how the agency will use the information we gather.

Justification #25: Adding the section titles organizes the form better and makes it easier to understand. This section title and the following paragraph highlight the reason we are requesting the information in this section: to gather information on potential work incentives.

• Change #26: On Page 6, we revised the language in Question 5 and changed the question number to “5A.”

• Current Language: “For any job(s) that you told us about in Question 3, have you worked under any special conditions listed below?”

• Revised Language: “Having extra support on the job may result in SSA not counting part of your earnings when we decide if you are eligible for or can continue to receive benefits.

For any job(s) that you told us about in the EMPLOYMENT INFORMATION section (including the ADDITIONAL EMPLOYMENT INFORMATION page), do you get extra support, easier work, or more time to do your work because of your disability?”

Justification #26: We changed the wording of this question to clarify why we are asking for this information and how providing it may help the beneficiary. We changed the language to accommodate the new format of the form. We added ‘YES’ and ‘NO’ check boxes for clarity and to improve the flow of the form. We also changed the question number to accommodate related questions to follow.

• Change #27: On Page 6, we removed the information gathering table and added Question 5B: “Please mark any below that apply, then go to question 5C.” We added four check box choices explaining possible accommodations, including an ‘other’ choice, and space to provide information about the employer providing the accommodation to each choice.

Justification #27: We added question 5B to fit with the new format and to improve the flow of the form. Removal of this table will reduce the burden on the claimant/beneficiary and reduce the psychological burden of the form. The series of statements are more specific and will assist the technician processing the claim or work issue CDR. The addition of the space to provide employer information specific to the employer makes the form easier to complete and reduces development for the technician.

• Change #28: On Page 7, we added Question 5C: “Does someone other than your employer have firsthand knowledge about the extra help, easier work, or extra time you get to do your work, because of your disability?” We allowed for a yes or no response, provided instructions on how to proceed and a space for the claimant/beneficiary to provide contact information, if there is an additional source. We added “Employment Network” and “Community Work Incentive Coordinator” (Ticket Partners) as potential sources for subsidy and special condition information. Also, we added additional space for the individual to provide any additional information about the accommodations.

Justification #28: We added question 5C to fit with the new format and to improve the flow of the form. Feedback from subject matter experts indicated that they would like to see this. It will aid the technician when developing for subsidy or special conditions. This change also compliments the expected changes to Form SSA-3033 Work Activity Questionnaire and Subsidy policy clarifications regarding who can provide this information. We added the additional space to improve the flow of the document and eliminate the need for the individual to go to a general remarks section at the end of the form.

• Change #29: On Page 7, we revised the language in Question 6 and changed the question number to 6A.

• Current Language: “For any job that you told us about in Question 3, did you make any of the changes below since the DATE shown in the Identification section (Check all that apply).”

• Revised Language: “We may not count short periods of substantial work (6 months or less) when we decide if you are eligible for benefits.

For any job(s) that you told us about in the EMPLOYMENT INFORMATION section (including the ADDITIONAL EMPLOYMENT INFORMATION page), did you make any changes to your work due to your disability, or due to the removal of special conditions that allowed you to work?

Examples of special conditions include, on-the-job coaching and similar services, close or continuous supervision or when the job coach or another employee performs part or all your job duties, because of your disabling condition.”

We provided “YES” and “NO” checkboxes with instructional information as to where to proceed.

Justification #29: We changed the question number to accommodate for follow up questions added. We changed the wording of this question to clarify why we are asking for this information and how providing it may help them. We changed the language to accommodate for the new format of the form and for simplification. The addition of the yes and no format negates the need for a negative reply later in the question and improves the flow of the form.

• Change #30: On Page 8, we added Question 6B: “Mark any that apply, provide requested information, then go to question 7A.” We removed the information gathering table and replaced it with a series of check boxed statements. The check boxed statements provide a simpler method for the beneficiary to let us know about a potential Unsuccessful Work Attempt (UWA).

Justification #30: On Page 8, we added Question 6B to fit with the format of the revised form and to improve the flow of the form. Removal of this table reduces the burden on the claimant/beneficiary and reduce the psychological burden of the form. The UWA statements are more specific and assist the technician processing the claim or work issue CDR. Adding the negative reply check box reduces ambiguity when the beneficiary is completing the form.

• Change #31: On Page 8, we added a section for the beneficiary to provide contact information for their employer at the time of the change.

Justification #31: The added section gives the claimant/beneficiary an opportunity to provide specific information about the change(s) and provides the technician contact information to verify the change(s).

• Change #32: On Page 8, we added additional space following Question 6B for the individual to provide any additional information about the accommodations.

Justification #32: The additional space improved the flow of the document and eliminated the need for the individual to go to a general remarks section at the end of the form.

• Change #33: On Page 8, we revised the language in Question 7 and changed the question number to 7A.

• Current Language: “Do you or did you spend any of your own money for items or services related to your physical and/or mental condition(s) that you needed in order to work and for which you did not get reimbursed? (For example; medicines or co-pays, medical devices or procedures, Braille equipment, special telephone or equipment, service animal, attendant care, modifications to a car used for work, or other special transportation.) We may ask you for proof of payment.”

• Revised Language: “We may be able to deduct certain expenses from your total (gross) wages before we decide if you are eligible to receive or continue to receive benefits. The expenses must be for items or services that you pay for, are needed because of your disability, and needed for you to work. The expenses must be paid for out of pocket. We cannot count expenses that Medicare, Medicaid, an insurance company, or another person paid or will pay back to you.

Examples of allowable expenses include medicines or co-pays, medical devices or procedures, special transportation, special telephone or other equipment, service animal, attendant care, or special equipment if you are blind, etc.

Did you spend any of your own money for items or services related to your disability that you needed for work?”

Justification #33: We changed the question number to fit the format of the revised form and to improve the flow of the form. We changed the language in this question to clarify why we are asking for this information and how the information may help the claimant/beneficiary. The simplified language makes the form easier to understand. The added language clarifying possible reimbursement choices for the expense reduces pre-completion contact or the collection of misinformation. We changed the language to accommodate for the new format of the form.

• Change #34: On Page 8, we added the statement “Examples of allowable expenses include medicines or co-pays, medical devices or procedures, special transportation, special telephone or other equipment, service animal, attendant care, or special equipment if you are blind, etc.”

Justification #34: We removed the examples from the actual question and provided an italicized statement of the examples. We also simplified the language in the examples.

• Change #35: On Page 8, we changed the language following the “NO” and “YES” choices.

Justification #35: We adapted the language for clarification and to comply with the new format of the form.

• Change #36: On Page 8, we added the statement “For each expense, we may ask you for proof of payment, that you needed the item or service because of an impairment(s) being treated by a healthcare provider, and how it helps you do your job.”

Justification #36: We separated this language from the checkboxes and added an italicized statement following the question to emphasize the information. We also revised the statement to better explain the qualifications of an Impairment Related Work Expense (IRWE). This provides for more complete allegations and assists the technician in IRWE development.

• Change #37: On Page 9, we added question 7B: “Please use this section to tell us about the item(s) or service(s), the date(s) you purchased them and what they cost. You should also tell us about recurring expenses.” We added an information gathering table, which allows the beneficiary to indicate exact expenses, costs, and dates. We also add a ‘Continuing’ cost indicator.

Justification #37: We added Question 7B to fit with the format of the revised form and to improve the flow of the form. We simplified the language to better instruct the claimant.

• Change #38: On Page 9, we added additional space following Question 6B for the individual to provide any additional information about the accommodations.

Justification #38: We improved the flow of the document and eliminated the need for the individual to go to a general remarks section at the end of the form by adding the additional space.

• Change #39: On Page 9, we removed the general ‘REMARKS’ section.

Justification #39: We removed the general ‘REMARKS’ section because we added additional space after the individual questions to improve the flow of the form and eliminate the need for the individual to page forward to a section at the end of the form.

• Change #40: On Page 9, we added “Payee” after “Representative” in the Signature Block.

Justification #40: Feedback from subject matter experts indicates that there is confusion as to who can sign the form. The change clarifies that it is the “Representative Payee” who can sign the form on behalf of the beneficiary, when applicable.

• Change #41: On Page 9, we revised the language preceding the witness signature blocks.

• Current Language: “If this statement is signed with a mark (e.g., X), two witnesses to the signing who know the person making the statement must sign below, giving their full addresses and telephone numbers.”

• Revised Language: “If this statement is signed with a mark (e.g., X), two individuals who know the person making the statement must witness the signature and sign below, giving their full addresses and telephone numbers.”

Justification #41: Internal reviews with subject matter experts indicated that the current language often confused claimants. The claimants ignored the instructions, causing delays in returning the form. The language is simpler and provides emphasis on when witness signatures are required.

• Change #42: On Page 11, we revised the Additional Employment Information data gathering tables.

Justification #42: To match the changes within the Employment Information section of the form (See Changes 14-18), we revised the Additional Employment Information data gathering tables.

• Change #43: On Pages 1 through 11, we reduced page count (pre-PinPoint mockup) from 12 pages to 11 pages.

Justification #43: We reduced page count to lessen the burden on the claimant/beneficiary and the psychological cost of completing the form, make the form less intimidating and increase the return rate of the form. Once the ‘official’ mock-up is made prior to sending for clearance, the pagination may change with additional formatting.

• Change #44: We are revising the Privacy Act Statements on this collection.

Justification #44: SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statements on this collection.

SSA will make these revisions upon OMB approval. While we note we are making extensive changes to the informative portions of this form, we do not believe it will change the overall burden on the respondent. Therefore, we believe the burden stated in #12 of the Supporting Statement remains accurate.