43804 Federal Register / Vol. 82, No. 180 / Tuesday, September 19, 2017 / Notices 

SOCIAL SECURITY ADMINISTRATION 

[Docket No: SSA–2017–0052] 

Agency Information Collection 

Activities: Proposed Request and 

Comment Request 

The Social Security Administration 

(SSA) publishes a list of information 

collection packages requiring clearance 

by the Office of Management and 

Budget (OMB) in compliance with 

Public Law 104–13, the Paperwork 

Reduction Act of 1995, effective October 

1, 1995. This notice includes revisions 

and extensions of OMB-approved 

information collections. 

SSA is soliciting comments on the 

accuracy of the agency’s burden 

estimate; the need for the information; 

its practical utility; ways to enhance its 

quality, utility, and clarity; and ways to 

minimize burden on respondents, 

including the use of automated 

collection techniques or other forms of 

information technology. Mail, email, or 

fax your comments and 

recommendations on the information 

collection(s) to the OMB Desk Officer 

and SSA Reports Clearance Officer at 

the following addresses or fax numbers. 

(OMB) Office of Management and 

Budget, Attn: Desk Officer for SSA, 

Fax: 202–395–6974, Email address: 

OIRA_Submission@omb.eop.gov. 

(SSA) Social Security Administration, 

OLCA, Attn: Reports Clearance 

Director, 3100 West High Rise, 6401 

Security Blvd., Baltimore, MD 21235, 

Fax: 410–966–2830, Email address: 

OR.Reports.Clearance@ssa.gov. Or 

you may submit your comments 

online through www.regulations.gov, 

referencing Docket ID Number [SSA– 

2017–0052]. 

I. The information collections below 

are pending at SSA. SSA will submit 

them to OMB within 60 days from the 

date of this notice. To be sure we 

consider your comments, we must 

receive them no later than November 20, 

2017. Individuals can obtain copies of 

the collection instruments by writing to 

the above email address. 

1. Letter to Employer Requesting 

Information About Wages Earned By 

Beneficiary—20 CFR 404.1520, 20 CFR 

404.1571–404.1576, 20 CFR 404.1584– 

404.1593, and 20 CFR 416.971– 

416.976—0960–0034. Social Security 

disability recipients receive payments 

based on their inability to engage in 

substantial gainful activity (SGA) 

because of a physical or mental 

condition. If the recipients work, SSA 

must evaluate and determine if they 

continue to meet the disability 

requirements of the law. Therefore, we 

use Form SSA–L725 to request monthly 

earnings information from the 

recipient’s employer. We then use the 

earnings data to determine whether the 

recipient is engaging in SGA, since work 

after a recipient becomes entitled to 

benefits can cause a cessation of 

disability. The respondents are 

businesses that employ Social Security 

disability recipients. 

Type of Request: Revision of an OMBapproved information collection. 

Modality of completion Number of 

respondents 

Frequency 

of response 

Average 

burden per 

response 

(minutes) 

Estimated 

total annual 

burden 

(hours) 

SSA–L725 ........................................................................................................ 150,000 1 40 100,000 

2. Certification of Low Birth Weight 

for SSI Eligibility of Funds You Provided 

to Another and Statement of Funds You 

Received—20 CFR 416.931, 

416.926a(m), and 416.924—0960–0720. 

Hospitals and claimants use Form SSA– 

3380 to provide medical information to 

local field offices (FO) and the Disability 

Determination Services (DDS) on behalf 

of infants with low birth weight. FOs 

use the form as a protective filing 

statement, and the medical evidence 

respondents provide on the form to 

make presumptive disability findings, 

which allow expedited payment to 

eligible claimants. DDSs use the medical 

information to determine disability and 

continuing disability. The respondents 

are hospitals and claimants who have 

information identifying low birth weight 

babies and their medical conditions. 

Type of Request: Revision of an OMBapproved information collection. 

Modality of completion Number of 

respondents 

Frequency 

of response 

Average 

burden per 

response 

(minutes) 

Estimated 

total annual 

burden 

(hours) 

SSA–3380 ........................................................................................................ 28,125 1 15 7,031 

II. SSA submitted the information 

collections below to OMB for clearance. 

Your comments regarding these 

information collections would be most 

useful if OMB and SSA receive them 30 

days from the date of this publication. 

To be sure we consider your comments, 

we must receive them no later than 

October 19, 2017. Individuals can obtain 

copies of the OMB clearance packages 

by writing to OR.Reports.Clearance@

ssa.gov. 

1. Statement of Marital Relationship 

(By one of the parties)—20 CFR 

404.726—0960–0038. SSA must obtain a 

signed statement from a spousal 

applicant if the applicant claims a 

common-law marriage to the insured in 

a state in which such marriages are 

recognized, and no formal marriage 

documentation exists. SSA uses 

information we collect on Form SSA– 

754–F4 to determine if an individual 

applying for spousal benefits meets the 

criteria of common-law marriage under 

state law. The respondents are 

applicants for spouse’s Social Security 

benefits or Supplemental Security 

Income (SSI) payments. 

Type of Request: Revision of an OMBapproved information collection. 


asabaliauskas on DSKBBXCHB2PROD with NOTICES
Federal Register / Vol. 82, No. 180 / Tuesday, September 19, 2017 / Notices 43805 

Modality of completion Number of 

respondents 

Frequency 

of response 

Average 

burden per 

response 

(minutes) 

Estimated 

total annual 

burden 

(hours) 

SSA–754–F4 .................................................................................................... 30,000 1 30 15,000 

2. Workers’ Compensation/Public 

Disability Questionnaire—20 CFR 

404.408—0960–0247. 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. 

Respondents are Title Title II disability 

applicants who receive both disability 

insurance benefits and worker’s 

compensation. 

Type of Request: Extension of an 

OMB-approved information collection. 

Modality of completion Number of 

respondents 

Frequency 

of response 

Average 

burden per 

response 

(minutes) 

Estimated 

total annual 

burden 

(hours) 

SSA–546 MCS Screens .................................................................................. 248,000 1 15 62,000 

3. Medicaid Use Report—20 CFR 

416.268—0960–0267. Section 20 CFR 

416.268 of the Code of Federal 

Regulations requires SSA to determine 

eligibility for: (1) Special SSI cash 

payments and, (2) special SSI eligibility 

status for a person who works despite a 

disabling condition. Section 20 CFR 

416.268 also provides that, to qualify for 

special SSI eligibility status, an 

individual must establish that 

termination of eligibility for benefits 

under Title XIX of the Act would 

seriously inhibit the ability to continue 

employment. SSA employees collect the 

information this regulation requires 

from respondents during a personal 

interview. We then use this information 

to determine if an individual is entitled 

to special Title XVI SSI payments and, 

consequently, to Medicaid. The 

respondents are SSI recipients for whom 

SSA has stopped payments based on 

earnings. 

Type of Request: Extension of an 

OMB-approved information collection. 

Regulation section Number of 

respondents 

Frequency 

of response 

Average 

burden per 

response 

(minutes) 

Estimated 

total annual 

burden 

(hours) 

20 CFR 416.268 .............................................................................................. 60,000 1 3 3,000 

4. Public Information Campaign— 

0960–0544. Periodically, SSA sends 

various public information materials, 

including public service 

announcements; news releases; and 

educational tapes, to public 

broadcasting systems so they can inform 

the public about various programs and 

activities SSA conducts. SSA frequently 

sends follow-up business reply cards for 

these public information materials to 

obtain suggestions for improving them. 

The respondents are broadcast sources. 

Type of Request: Revision of an OMBapproved information collection. 

Modality of completion Number of 

respondents 

Frequency 

of response 

Number of 

respondents 

Average 

burden per 

response 

(minutes) 

Estimated 

total annual 

burden 

(hours) 

Radio .................................................................................... 5,000 2 10,000 1 167 

5. Help America Vote Act—0960– 

0706. House Rule 3295, the Help 

America Vote Act of 2002, mandates 

that States verify the identities of newly 

registered voters. When newly 

registered voters do not have driver’s 

licenses or State-issued ID cards, they 

must supply the last four digits of their 

Social Security number to their local 

State election agencies for verification. 

The election agencies forward this 

information to their State Motor Vehicle 

Administration (MVA), and the State 

MVA inputs the data into the American 

Association of MVAs, a central 

consolidation system that routes the 

voter data to SSA’s Help America Vote 

Verification (HAVV) system. Once 

SSA’s HAVV system confirms the 

identity of the voter, the information 

returns along the same route in reverse 

until it reaches the State election 

agency. The respondents are the State 

MVAs seeking to confirm voter 

identities. 

Correction Notice: SSA is updating 

the burden information for this 

collection, so it differs from the 

information we published at 82 FR 

31132, on 7/5/17. We are also including 

the cost burden, which we inadvertently 

did not publish in the previous Notice. 

Type of Request: Revision of an OMBapproved information collection. 


asabaliauskas on DSKBBXCHB2PROD with NOTICES
43806 Federal Register / Vol. 82, No. 180 / Tuesday, September 19, 2017 / Notices 

Modality of completion Number of 

respondents 

Frequency 

of response 

Number of 

responses 

Average 

burden per 

response 

(minutes) 

Estimated 

total annual 

burden 

(hours) 

HAVV ................................................................................... 48 102,877 4,938,096 2 164,603 

Cost Burden: The 48 State MVAs 

participating in HAVA each pay an 

annual maintenance cost. Additionally, 

States pay .02 cents per verification 

request. Therefore, the total cost to 

respondents is $291,348. 

6. Medicare Subsidy Quality Review 

Forms—20 CFR 418(b)(5)—0960–0707. 

The Medicare Modernization Act of 

2003 mandated the creation of the 

Medicare Part D prescription drug 

coverage program and provides certain 

subsidies for eligible Medicare 

beneficiaries to help pay for the cost of 

prescription drugs. As part of its 

stewardship duties of the Medicare Part 

D subsidy program, SSA must conduct 

periodic quality review checks of the 

information Medicare beneficiaries 

report on their subsidy applications 

(SSA–1020, OMB No. 0960–0696). SSA 

uses the Medicare Quality Review 

program to conduct these checks. The 

respondents are applicants for the 

Medicare Part D subsidy whom SSA 

chose to undergo a quality review. 

Type of Request: Revision of an OMBapproved information collection. 

Form No. and name Number of 

respondents 

Frequency 

of response 

Average 

burden per 

response 

(minutes) 

Estimated 

total annual 

burden 

(hours) 

SSA–9301 (Medicare Subsidy Quality Review Case Analysis Questionnaire) 3,500 1 30 1,750 

SSA–9302 (Notice of Quality Review Acknowledgement Form for those with 

Phones) ........................................................................................................ 3,500 1 15 875 

SSA–9303 (Notice of Quality Review Acknowledgement Form for those 

without Phones) ........................................................................................... 350 1 15 88 

SSA–9308 (Request for Information) .............................................................. 7,000 1 15 1,750 

SSA–9310 (Request for Documents) .............................................................. 3,500 1 5 292 

SSA–9311 (Notice of Appointment—Denial—Reviewer Will Call) .................. 450 1 15 113 

SSA–9312 (Notice of Appointment—Denial—Please Call Reviewer) ............. 50 1 15 13 

SSA–9313 (Notice of Quality Review Acknowledgement Form for those with 

Phones) ........................................................................................................ 2,500 1 15 625 

SSA–9314 (Notice of Quality Review Acknowledgement Form for those 

without Phones) ........................................................................................... 500 1 15 125 

Totals ........................................................................................................ 21,350 ........................ ........................ 5,631 

7. Electronic Records Express (Third 

Parties)—20 CFR 404.1700—404.1715— 

0960–0767. Electronic Records Express 

(ERE) is an online system which enables 

medical providers and various third 

party representatives to download and 

submit disability claimant information 

electronically to SSA as part of the 

disability application process. To ensure 

only authorized people access ERE, SSA 

requires third parties to complete a 

unique registration process if they wish 

to use this system. This information 

collection request (ICR) includes the 

third-party registration process; the 

burden for submitting evidence to SSA 

is part of other, various ICRs. The 

respondents are third party 

representatives of disability applicants 

or recipients who want to use ERE to 

electronically access clients’ disability 

files online and submit information to 

SSA. 

Type of Request: Revision of an OMBapproved information collection. 

Modality of completion Number of 

respondents 

Frequency 

of response 

Number of 

responses 

Average 

burden per 

response 

(minutes) 

Estimated 

total annual 

burden 

(hours) 

ERE—Third Parties .............................................................. 10,413 319 3,321,747 1 55,362 

Dated: September 13, 2017. 

Naomi R. Sipple, 

Reports Clearance Officer, Social Security 

Administration. 

[FR Doc. 2017–19865 Filed 9–18–17; 8:45 am] 

BILLING CODE 4191–02–P 


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