Site Review Questionnaires for Volume and Fee-for-Service Payees and Beneficiary Interview Form

Forms and Documents

Document Name	Status
Form SSA-637 Site Review Questionnaires for Volume and Fee-for-Service Payees Form	Modified
Form SSA-639 Expanded Monitoring Site Review: Beneficiary Interview Form Form	Modified
Supporting Statement - 0960-0633.docx Supporting Statement A	2015-10-27
Addendum 0960-0633.docx Supplementary Document	2015-10-27

IC Document Collections

IC ID	Document Title	Status
38057	Site Review Questionnaires for Volume and Fee-for-Service Payees Form	Modified
178591	Expanded Monitoring Site Review: Beneficiary Interview Form Form	Modified

ICR Details

OMB Control No: 0960-0633	ICR Reference No: 201507-0960-011
Status: Historical Active	Previous ICR Reference No: 201209-0960-008
Agency/Subagency: SSA	Agency Tracking No:
Title: Site Review Questionnaires for Volume and Fee-for-Service Payees and Beneficiary Interview Form
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: 12/15/2015
	Date Received in OIRA: 10/27/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2018	36 Months From Approved	01/31/2016
Responses	10,292	0	10,292
Time Burden (Hours)	5,380	0	5,380
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA uses the SSA-637, Site Review Questionnaire for Volume and Fee-for-Service Payees, to obtain information from payees about how the organization operates and carries out its representative payee responsibilities, including how it manages beneficiary funds. We then use the SSA-639, Beneficiary Interview Form, to obtain information from the beneficiaries to help corroborate the payee's statements. Due to the sensitivity of the information, SSA employees always complete the forms based on the answers respondents give during the interview. This collection is mandatory for representative payees and voluntary for beneficiaries. SSA will not allow representative payees who do not respond to continue serving as representative payees. The respondents are individuals, State and local governments, non-profit and for-profit organizations that serve as representative payees and the beneficiaries they serve.

---

Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: The Social Security Act
   PL: Pub.L. 108 - 203 102(b) Name of Law: The Social Security Protection Act
   US Code: 42 USC 405 Name of Law: The 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:
	80 FR 43828	07/23/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 57907	09/25/2015
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Expanded Monitoring Site Review: Beneficiary Interview Form	SSA-639	Expanded Monitoring Site Review Beneficiary Review Form
Site Review Questionnaires for Volume and Fee-for-Service Payees	SSA-637	Expanded Monitoring Site Review Questionnaire for Volume and Fee for Service Payees

---

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	10,292	10,292	0	0	0	0
Annual Time Burden (Hours)	5,380	5,380	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: $233,069

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

---

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: 10/27/2015

---