Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
a) 20 CFR 411.140(d)(2) - Ticket Assignability - IVR Automated Telephone Unchanged 6000 300 0
a) 20 CFR 411.140(d)(2) - Ticket Assignability - Portal Unchanged 91484 3049 0 Other-Internet Screens
Other-Internet Screens
Other-screens
a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1365 State Agency Ticket Assignment Form Unchanged 948 237 0 Other-screens
a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a); 411.465- Individualized Work Plan - SSA-1370 Unchanged 26007 26007 0 Form and Instruction SSA-1370
a) 20 CFR 411.166; 411.170(b) - Elecronic Data Sharing Unchanged 4104 342 0 Other-screens
b) 20 CFR 411.145 & 411.325 - Requesting Ticket Unassignments Unchanged 2494 624 0 Other-screens
Other-screens
b) 20 CFR 411.535(a)(1)(iii) - VR Case Closures Unchanged 136478 25021 0
c) 20 CFR 411.200(b) - SSA-1375 Unchanged 179 90 0 Form SSA-1375
d) 20 CFR 411.505 - Selecting a Payment System Unchanged 33 6 0
e) 20 CFR 411.400-411.420, 411.325(d), 411.415 - Reporting Referral Agreement Unchanged 31 8 0
f) 20 CFR 411.560 - SSA-1401, Split Payment Situations Modified 5 2 0 Form SSA-1401
f) 20 CFR 411.575 - Requesting EN Payments - SSA-1391; SSA-1398 Modified 1704 1136 0 Form and Instruction SSA-1391
Form and Instruction SSA-1389
g) 20 CFR 411.325 (f)- Annual Performance Unchanged 507 127 0 Other-Annual Performance Outcome Report
g) 20 CFR 411.325 (f)- Certification of Services Unchanged 2438 813 0
g) 20 CFR 411.325(f) - Proof of Relationship Unchanged 6870 2290 0 Instruction
h) 20 CFR 411.435, 411.615, 411.625 - Dispute Resolutions Unchanged 196 392 0
i) 20 CFR 411.320 - SSA-1374, EN Contract Changes Unchanged 929 77 0 Form and Instruction SSA-1394
j) 20 CFR 411.200(b) - WISE Webinar Survey Unchanged 1776 89 0 Other-Wise Survey
j) 20 CFR 411.200(b) WISE Webinar Registration Page Unchanged 4000 200 0 Other-online registration form
Total burden requested under this ICR: 286183 60810 0  
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