Supporting Statement for OMB Clearance for the SSA-84
Treating Physician Consultative Examination Interest Form
20 CFR 404.1519g-404.1519i
0960-0751
A. Justification
Introduction/Authoring Laws and Regulations
20 CFR 404.1519g, 404.1519h, and 404.1519i of the Code of Federal Regulations state that individuals’ treating physicians (TP) are the preferred source to perform a consultative examination (CE). The method by which the Social Security Administration (SSA) ascertains whether the TP is interested in performing the CE is through the collection of information on the SSA-84.
Description of Collection
When an applicant for Social Security disability benefits has not consulted a physician for a specified period preceding the application, SSA will ask the applicant to complete a CE. If the applicant has a TP, SSA mails Form SSA-84 with a medical evidence of record (MER) request letter (0960-0555).
The TP completes the latter form and mails it to SSA to indicate interest in conducting the CE. If the TP does not return the form, SSA assumes the TP is not interested in performing the CE. Respondents are disability benefits applicants’ treating physicians.
Use of Information Technology to Collect the Information
SSA did not create an electronic version of form SSA-84 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 11,092 respondents complete the form. This is less than the GPEA cut-off of 50,000.
Why We Cannot Use Duplicate Information
State DDS forms approved under OMB 0960-0555 collect information similar to Form SSA-84. The respondents do not supply the same information twice (once to State agencies and then again to SSA). The state DDS will collect information (because they are processing the case) or the OMVE will collect the information (because we are processing the case), but not by both. Whoever has jurisdiction of the case between the DDS or SSA sends the forms, only one can have the case at any given level.
Each State we assist uses their own forms and procedures to collect the same information we are asking for on the SSA-84. However, as a Federal component, we do not have the authority to use the State's forms. Because we assist many States with their disability workloads, we need standardized Federal forms that we can use in any State we assist.
5. Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-84, SSA would be unable to determine whether the claimants’ TPs are willing and capable of conducting the CE. Because we only collect this information on a voluntary basis, we cannot collect it less frequently.
There are no technical or legal obstacles to burden reduction.
7. Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on March 04, 2010, at 75 FR 9992, and we received no public comments. SSA published the second Notice on, May 13, 2010, at 75 FR 27036. If we receive comments in response to the 30-day Notice, we will forward them to OMB. We did not consult with the public on the revision of this form.
Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
Assurances of Confidentiality
SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Approximately 168 respondents take 5 minutes each to complete form SSA-84 each year. Accordingly, the burden is 14 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
13. Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden to the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $259. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
15. Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.
16. Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
17. Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).
B. Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
| File Type | application/msword |
| File Title | Title of Information Collection and Form Number(s) |
| Author | Naomi |
| Last Modified By | 666429 |
| File Modified | 2010-05-18 |
| File Created | 2010-03-22 |