Statutory Benefit Continuation Election Statement

Forms and Documents

Document Name	Status
Form SSA-792 Statutory Benefit Continuation Election Statement- Hearing Appeal Level: Form Form and Instruction	New
Form SSA-792 Statutory Benefit Continuation Election Statement -Reconsideration Appeal Level: Form and Instruction	New
0960-NEW Statutory Benefit Continuation Election Statement .docx Supporting Statement A	2024-10-25

IC Document Collections

IC ID	Document Title	Status
271879	Statutory Benefit Continuation Election Statement- Hearing Appeal Level: Form Form and Instruction	New
271877	Statutory Benefit Continuation Election Statement -Reconsideration Appeal Level: Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202410-0960-021
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Statutory Benefit Continuation Election Statement
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/25/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	77,145	0
Time Burden (Hours)	120,861	0
Cost Burden (Dollars)	0	0

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Abstract: Under current policy, the individual records their request on the form SSA-795, Statement of Claimant or Other Person (OMB 0960-0045). When the individual submits a writing of their own, the written statement often does not include all the necessary information. Field office staff must often contact the individual to explain the available options. In addition, the individual has 15 calendar days from the notice date to submit their election to continue benefits, which often results in the individual having to visit the local field office in person to meet the deadline. SSA will use the Statutory Benefit Continuation Election Statement, Form SSA-792 to standardize our collection of an individual’s benefit continuation election choice. This new information collection allows the individual to elect from a variety of options available to them for continued disability benefits and Medicare coverage.

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Authorizing Statute(s): None

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 67141	08/19/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 84431	10/22/2024
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Statutory Benefit Continuation Election Statement -Reconsideration Appeal Level:	SSA-792	Statutory Benefit Continuation Election Statement
Statutory Benefit Continuation Election Statement- Hearing Appeal Level: Form	SSA-792	Statutory Benefit Continuation Election Statement

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ICR Summary of Burden

	Total Request	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	77,145	0	0	77,145	0	0
Annual Time Burden (Hours)	120,861	0	0	120,861	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new form that increases the public reporting burden. See question #12 for updated burden figures. * Note: The total burden reflected in ROCIS is 120,861, while the burden cited in #12 of the Supporting Statement is 51,430. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a 30-minute, one-way, drive burden + learning costs. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

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Annual Cost to Federal Government: $952,900

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: 10/25/2024

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