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	Unchanged
Form SSA-1370 c.) 20 CFR 411.200(b) Virtual Job Fair Registration - Individuals Form and Instruction	New
Form SSA-1370 a.) 20 CFR 411.140(d)(3) Virtual Job Fair Registration - Employment Networks Form and Instruction	New
Form SSA-1401 f) 20 CFR 411.560 - SSA-1401, Split Payment Situations Form	Unchanged
Form SSA-1394 i) 20 CFR 411.320 - SSA-1394, EN Contract Changes Form and Instruction	Unchanged
Form SSA-1391 f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398 Form and Instruction	Unchanged
Form SSA-1375 c) 20 CFR 411.200(b) - SSA-1375 (and cover letters) Form	Unchanged
Justification for Non-Substantive Change 0960-0644.docx Justification for No Material/Nonsubstantive Change	2015-06-24

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	Unchanged
217179	c.) 20 CFR 411.200(b) Virtual Job Fair Registration - Individuals Form and Instruction	New
217178	a.) 20 CFR 411.140(d)(3) Virtual Job Fair Registration - Employment Networks Form and Instruction	New
208203	20 CFR 411.200(b) WISE Webinar Registration Page Other-online registration form	Unchanged
203490	i) 20 CFR 411.320 - EN Contract Changes, Portal Other-Internet Screens	Unchanged
201989	a) 20 CFR 411.140(d)(2) - Ticket Assignability - Portal Other-Internet Screens	Unchanged
201988	a) 20 CFR 411.140(d)(2) - Ticket Assignability - IVR Automated Telephone	Unchanged
201843	f) 20 CFR 411.575 - Automatic Payments (SSA-1391 et al)	Unchanged
201842	f) 20 CFR 411.575 - Portal Screens (SSA-1391 et al)	Unchanged
201841	c) 20 CFR 411.200(b) - Request for Certification of Work Portal Screens Other-Internet Screens	Unchanged
201838	b) 20 CFR 411.145; 411.325 - Unassignments Portal Screens Other-screens	Unchanged
201837	a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370 Portal Screens Other-screens	Unchanged
190323	f) 20 CFR 411.560 - SSA-1401, Split Payment Situations Form	Unchanged
190204	i) 20 CFR 411.320 - SSA-1394, EN Contract Changes Form and Instruction	Unchanged
184464	h) 20 CFR 411.435, 411.615, 411.625 - Dispute Resolutions	Unchanged
184463	g) 20 CFR 411.325(f) - Periodic Outcomes Reporting	Unchanged
184462	f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398 Form and Instruction	Unchanged
184461	e) 20 CFR 411.325(d), 411.415 - Reporting Referral Agreement	Unchanged
184460	d) 20 CFR 411.365, 411.505, 411.515 - Selecting a Payment System	Unchanged
184459	c) 20 CFR 411.210(b) -Ticket-Use Status after Not Making Timely Progress	Unchanged
184457	c) 20 CFR 411.200(b) - SSA-1375 (and cover letters) Form	Unchanged
184456	c) 20 CFR 411.192(b)&(c) - Request to Place Ticket in Inactive Status	Unchanged
184450	b) 20 CFR 411.535(a)(1)(iii) - VR Case Closures	Unchanged
184449	b) 20 CFR 411.145 & 411.325 - Requesting Ticket Unassignments Other-screens	Unchanged
184447	a) 20 CFR 411.166; 411.170(b) - Elecronic Data Sharing Other-screens	Unchanged

ICR Details

OMB Control No: 0960-0644	ICR Reference No: 201506-0960-011
Status: Historical Active	Previous ICR Reference No: 201408-0960-012
Agency/Subagency: SSA	Agency Tracking No:
Title: The Ticket to Work and Self-Sufficiency Program, 20 CFR 411
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: 08/14/2015
	Date Received in OIRA: 06/24/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2015	11/30/2015	11/30/2015
Responses	369,914	0	360,414
Time Burden (Hours)	57,416	0	55,833
Cost Burden (Dollars)	0	0	0

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Abstract: SSA is requesting to incorporate a new modality of the collection instrument Form SSA-1370, an electronic, web-based version of the individual work plan to assist Ticket to Work program participants to take advantage of increased employment opportunities via virtual job fairs. 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: Social Security Act
   US Code: 42 USC 1320b¿19 Name of Law: Social Security Act
  

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:
	77 FR 47908	08/10/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 65044	10/24/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 25

IC Title	Form No.	Form Name
a.) 20 CFR 411.140(d)(3) Virtual Job Fair Registration - Employment Networks	SSA-1370	Ticket to Work Virtural Job Fair Registration
c.) 20 CFR 411.200(b) Virtual Job Fair Registration - Individuals	SSA-1370	Virtual Job Fair Registration - Individuals
a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1370 Portal Screens
c) 20 CFR 411.200(b) - Request for Certification of Work Portal Screens
f) 20 CFR 411.575 - Automatic Payments (SSA-1391 et al)
f) 20 CFR 411.575 - Portal Screens (SSA-1391 et al)
a) 20 CFR 411.140(d)(2) - Ticket Assignability - IVR Automated Telephone
a) 20 CFR 411.140(d)(2) - Ticket Assignability - Portal
b) 20 CFR 411.145; 411.325 - Unassignments Portal Screens
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
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 (and cover letters)	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
e) 20 CFR 411.325(d), 411.415 - Reporting Referral Agreement
a) 20 CFR 411.166; 411.170(b) - Elecronic Data Sharing
i) 20 CFR 411.320 - EN Contract Changes, Portal
20 CFR 411.200(b) WISE Webinar Registration Page

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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	369,914	360,414	0	0	9,500	0
Annual Time Burden (Hours)	57,416	55,833	0	0	1,583	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:

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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]? 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: 06/24/2015

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