Workers' Compensation/Public Disability Benefit Questionnaire

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-546 Workers’ Compensation / Public Disability Benefit Questionnaire	Form	Modified	Available
Justification for the Non-Substantive Changes -0960-0247 (signature removal).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-01-21	Repair queued
Justification for the Non-Substantive Changes -0960-0247 (signature removal).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-01-21	Repair queued
Supporting Statement - 0247.docx	Supporting Statement A	Uploaded 2021-01-28	Repair queued
Supporting Statement - 0247.docx	Supporting Statement A	Uploaded 2021-01-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9165	Workers' Compensation/Public Disability Benefit Questionnaire	Form	Modified	Workers’ Compensation / Public Disability Benefit Questionnaire
9165	Workers' Compensation/Public Disability Benefit Questionnaire	Other-Inernal Intranet Screens	Modified

ICR Details

OMB Control No: 0960-0247	ICR Reference No: 202501-0960-007
Status: Active	Previous ICR Reference No: 202010-0960-011
Agency/Subagency: SSA	Agency Tracking No:
Title: Workers' Compensation/Public Disability Benefit Questionnaire
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/27/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/21/2025
Terms of Clearance: Approved consistent with the agency's commitments under Sec. 4 (k)(iii) and (iv) of E.O. 14058.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2027	11/30/2027	11/30/2027
Responses	248,000	0	248,000
Time Burden (Hours)	186,000	0	186,000
Cost Burden (Dollars)	0	0	0

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Abstract: Section 224 of the Social Security Act (Act) provides for the reduction of disability insurance benefits (DIB) when the combination of DIB and any workers’ compensation (WC) or certain Federal, State or local public disability benefits (PDB) exceeds 80 percent of the worker’s pre-disability earnings. SSA field office staff conduct face-to-face interviews with applicants using the electronic SSA-546 WC/PDB screens in the Modernized Claims System (MCS) to determine if the worker’s receipt of WC or PDB payments will cause a reduction of DIB. The respondents are applicants for theTitle II DIB. We are submitting this change request for removal of the signature requirement.

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Authorizing Statute(s): US Code: 42 USC 424 Name of Law: Social Security 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:
	85 FR 76142	11/27/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 7446	01/28/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Workers' Compensation/Public Disability Benefit Questionnaire	SSA-546	Workers’ Compensation / Public Disability Benefit Questionnaire

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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	248,000	248,000	0	0	0	0
Annual Time Burden (Hours)	186,000	186,000	0	0	0	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: The burden increase includes the 30 minute travel time as required by OIRA.

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Annual Cost to Federal Government: $1,359,220

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: 01/21/2025

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