Work Activity Report (Self-Employed Person)

Forms and Documents

Document Name	Status
Form SSA-820-BK Work Activity Report (Self-Employed Person), 20 CFR 404.1520(b), 404.1571-.1576, 404.1584-.1593, 416.971-.976 Form	Modified
Form SSA-820-BK Work Activity Report (Self-Employed Person), 20 CFR 404.1520(b), 404.1571-.1576, 404.1584-.1593, 416.971-.976 Form	Modified
Justification_of_a_Non-Substantive_Change_Request 0598.doc Justification for No Material/Nonsubstantive Change	2011-10-05

IC Document Collections

IC ID	Document Title	Status
9580	Work Activity Report (Self-Employed Person), 20 CFR 404.1520(b), 404.1571-.1576, 404.1584-.1593, 416.971-.976 Form	Modified
197206	Work Activity Report (Self-Employed Person), 20 CFR 404.1520(b), 404.1571-.1576, 404.1584-.1593, 416.971-.976 Form	Modified

ICR Details

OMB Control No: 0960-0598	ICR Reference No: 201110-0960-001
Status: Historical Active	Previous ICR Reference No: 201104-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Work Activity Report (Self-Employed Person)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/20/2011
	Date Received in OIRA: 10/18/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2014	04/30/2014	04/30/2014
Responses	100,000	0	100,000
Time Burden (Hours)	37,500	0	37,500
Cost Burden (Dollars)	0	0	0

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Abstract: Section 223(d)(4) and Section 1633 of the Social Security Act provide for collection of evidence necessary to determine initial or continuing eligibility for Supplemental Security Income or Social Security disability benefits. An individual's entitlement to benefits ends if he/she demonstrates an ability to perform substantial gainful activity (GSA). This form is used to determine whether work an individual performs in self-employment is at the SGA level. This non-substantive change request change the signature on the cover letter of the SSA-820-BK.

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Authorizing Statute(s): None

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:
	75 FR 52578	08/26/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 80563	12/22/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Work Activity Report (Self-Employed Person), 20 CFR 404.1520(b), 404.1571-.1576, 404.1584-.1593, 416.971-.976	SSA-820-BK	Work Activity Report (Self-Employment)
Work Activity Report (Self-Employed Person), 20 CFR 404.1520(b), 404.1571-.1576, 404.1584-.1593, 416.971-.976	SSA-820-BK	WORK ACTIVITY REPORT (Self-Employed Person)

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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	100,000	100,000	0	0	0	0
Annual Time Burden (Hours)	37,500	37,500	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: We are making revisions to clarify the language, remove questions, and streamline the form to make it easier for respondents to use. We anticipate these actions will decrease the burden hours for this form. Based on our change in procedure, we estimate only half the respondents will take the entire 30 minutes to complete the SSA-820-F4, while the other half will have a reduced burden of 15 minutes to complete the form.

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Annual Cost to Federal Government: $308,000

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 10/18/2011

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