View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0960-0098
ICR Reference No:
200902-0960-001
Status:
Historical Active
Previous ICR Reference No:
200606-0960-002
Agency/Subagency:
SSA
Agency Tracking No:
Title:
Request for Workers' Compensation/Public Disability Benefit Information
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
10/02/2009
Retrieve Notice of Action (NOA)
Date Received in OIRA:
06/11/2009
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
10/31/2012
36 Months From Approved
10/31/2009
Responses
120,000
0
120,000
Time Burden (Hours)
30,000
0
30,000
Cost Burden (Dollars)
0
0
0
Abstract:
SSA uses Form SSA-1709 to verify WorkerÂ’s Compensation/Public Disability Benefits (WC/PDB). SSA uses the information to compute the correct reduction of Disability Insurance Benefits (DIB). The claimant may be able to furnish adequate verification of the WC/PDB benefits by submitting a copy of his or her award notice, benefit check, etc. SSA considers the claimant as the primary source of verification, and if he or she provides the necessary evidence, the form is not used. If the claimant cannot provide evidence, the only other reliable source of this information is the entity giving the benefits, its agent (such as an insurance carrier), or an administering public agency. The respondents are Federal, State, and local agencies administering WC/PDB, insurance carriers and public or private self-insured companies.
Authorizing Statute(s):
US Code:
42 USC U.S.C. 424a
Name of Law: Social Security Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
74 FR 12170
03/23/2009
30-day Notice:
Federal Register Citation:
Citation Date:
74 FR 23916
05/21/2009
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Request for Workers' Compensation/Public Disability Benefit Information, 20 CFR 404.408(e)
SSA-1709
Request for Worker's Compensation/Public Disability Benefit Information
ICR Summary 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
120,000
120,000
0
0
0
0
Annual Time Burden (Hours)
30,000
30,000
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:
Annual Cost to Federal Government:
$600,000
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Uncollected
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Uncollected
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
John Biles 410 965-3758 John.Biles@ssa.gov
Common Form ICR:
No
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:
06/11/2009
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