The Ticket to Work and Self-Sufficiency Program, 20 CFR 411

Forms and Documents

Document Name	Status
Form SSA-1370 a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370 Form and Instruction	Modified
Form SSA-1392 f) 20 CFR 411.575; SSA-1392 - EN Payment Status Report Request Form and Instruction	New
Form SSA-1401 f) 20 CFR 411.560, SSA-1401 - Split Payment Situations Form	New
Form SSA-1394 i) 20 CFR 411.320; SSA-1394 - EN Contract Changes Form and Instruction	New
Form SSA-1365 a) 411.140(d)(3); 411.325(a); 411.150(b)(3) - SSA-1365 Form	Modified
Form SSA-1391 f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398 Form and Instruction	Modified
Form SSA-1375 20 CFR 411.200(b)--SSA-1375 Internet Version (State ENs) Form	Removed
Form SSA-1375 c) 20 CFR 411.200(b) - SSA-1375; SSA-L1373; SSA-L1374; SSA-L1377 Form	Modified
Addendum - 0644.doc Supplementary Document	2009-12-01
Supporting Statement - 0644.doc Supporting Statement A	2009-12-21

IC Document Collections

IC ID	Document Title	Status
9680	a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370 Form and Instruction	Modified
191126	f) 20 CFR 411.575; SSA-1392 - EN Payment Status Report Request Form and Instruction	New
190323	f) 20 CFR 411.560, SSA-1401 - Split Payment Situations Form	New
190204	i) 20 CFR 411.320; SSA-1394 - EN Contract Changes Form and Instruction	New
184502	a) 411.140(d)(3); 411.325(a); 411.150(b)(3) - SSA-1365 Form	Modified
184464	h) 20 CFR 411.435, 411.615, 411.625 -- Dispute Resolutions	Modified
184463	g) 20 CFR 411.325(f) - Periodic Outcomes Reporting	Modified
184462	f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398 Form and Instruction	Modified
184461	e) 20 CFR 411.325(d), 411.415 - Reporting Referral Agreement	Modified
184460	d) 20 CFR 411.365, 411.505, 411.515 - Selecting a Payment System	Modified
184459	c) 20 CFR 411.210(b) -Ticket-Use Status after Not Making Timely Progress	Modified
184458	20 CFR 411.200(b)--SSA-1375 Internet Version (State ENs) Form	Removed
184457	c) 20 CFR 411.200(b) - SSA-1375; SSA-L1373; SSA-L1374; SSA-L1377 Form	Modified
184456	c) 20 CFR 411.192(b)&(c) - Request to Place Ticket in Inactive Status	Modified
184450	b) 20 CFR 411.535(a)(1)(iii) - VR Case Closures	Modified
184449	b) 20 CFR 411.145 & 411.325 - Requesting Ticket Unassignments	Modified
184447	a) 20 CFR 411.166; 411.170(b) - Elecronic Data Sharing	Modified

ICR Details

OMB Control No: 0960-0644	ICR Reference No: 200907-0960-009
Status: Historical Active	Previous ICR Reference No: 200804-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: The Ticket to Work and Self-Sufficiency Program, 20 CFR 411
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: 04/20/2010
	Date Received in OIRA: 12/21/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2013	36 Months From Approved	04/30/2010
Responses	206,926	0	121,981
Time Burden (Hours)	63,502	0	46,553
Cost Burden (Dollars)	0	0	0

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Abstract: Through its Ticket to Work Program Manager, SSA uses the information collected to operate and manage the Ticket to Work Program. SSA uses the Ticket to Work Program to assign Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) beneficiaries to a service provider, and follows their progress through the various stages of ticket program participation such as progress reviews or changes in ticket status. Most of the collections in this request require service providers to provide information to SSA for such tasks as selecting a payment system or requesting payments for helping the beneficiary achieve certain work goals. Most of the categories of information collected in this request are required for SSA to be in compliance with the Ticket to Work legislation and provide proper oversight of the program. The respondents are SSDI beneficiaries and blind or disabled SSI beneficiaries and their employment networks or State vocational rehabilitation agencies under the Ticket to Work Program.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: null
   US Code: 42 USC 1320b–19 Name of Law: null
  

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:
	74 FR 45508	09/02/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 67945	12/21/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 16

IC Title	Form No.	Form Name
e) 20 CFR 411.325(d), 411.415 - Reporting Referral Agreement
a) 20 CFR 411.166; 411.170(b) - Elecronic Data Sharing
f) 20 CFR 411.575; SSA-1392 - EN Payment Status Report Request	SSA-1392	Employment Network Payment Status Report Request Form
a) 411.140(d)(3); 411.325(a); 411.150(b)(3) - SSA-1365	SSA-1365	State Agency Ticket Assignment Form Ticket to Work and Self-Sufficiency Program
g) 20 CFR 411.325(f) - Periodic Outcomes Reporting
a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370	SSA-1370	Ticket to Work Individual Work Plan
c) 20 CFR 411.192(b)&(c) - Request to Place Ticket in Inactive Status
c) 20 CFR 411.210(b) -Ticket-Use Status after Not Making Timely Progress
20 CFR 411.200(b)--SSA-1375 Internet Version (State ENs)	N/A, SSA-1375	Ticket to Work Progress Review Form ,   Electronic Data Exchange Response for Progress Reports (Draft Version)
f) 20 CFR 411.560, SSA-1401 - Split Payment Situations	SSA-1401	Employment Network Split Payment Request Form
i) 20 CFR 411.320; SSA-1394 - EN Contract Changes	SSA-1394	Employment Network Contract Change Form
b) 20 CFR 411.145 & 411.325 - Requesting Ticket Unassignments
b) 20 CFR 411.535(a)(1)(iii) - VR Case Closures
h) 20 CFR 411.435, 411.615, 411.625 -- Dispute Resolutions
c) 20 CFR 411.200(b) - SSA-1375; SSA-L1373; SSA-L1374; SSA-L1377	SSA-1375	Ticket to Work Progress Review Form
d) 20 CFR 411.365, 411.505, 411.515 - Selecting a Payment System
f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	SSA-1393, SSA-1391, SSA-1389, SSA-1399, SSA-1396, SSA-1398	Employment Network Payment Request Form ,   EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request) ,   Employment Network Supplemental Earnings Statement ,   Auto Pay Request Form ,   Earnings Inquiry Request Form ,   Self-Employment Income (SEI) Form Beneficiary Quarterly Report Self-Employment

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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	206,926	121,981	0	100,402	-15,457	0
Annual Time Burden (Hours)	63,502	46,553	0	20,440	-3,491	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The annual reporting burden for these information collections has increased due to the addition of new forms SSA-1391, SSA-1394, and SSA-1401; the new letter SSA-L1375; as well as the combination of two ICs (due to lack of funding, SSA did not create an Internet versions of the SSA-1375 as mentioned in the previous ICR. Rather we allow ENs to submit the form either via fax or email). We are also adjusting the burden for both the SSA-1365 and SSA 1370, which increases the public reporting burden.

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Annual Cost to Federal Government: $7,000,000

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

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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: 12/21/2009

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