Certificate of Incapacity

Forms and Documents

Document Name	Status
Form SSA-604 Certificate of Incapacity Form and Instruction	Modified
Supporting Statement - 0739 (Revised).docx Supporting Statement A	2019-09-03
Addendum - 0739.docx Supplementary Document	2019-05-09

IC Document Collections

IC ID	Document Title	Status
44832	Certificate of Incapacity Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0739	ICR Reference No: 201903-0960-011
Status: Active	Previous ICR Reference No: 201601-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Certificate of Incapacity
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/04/2019
	Date Received in OIRA: 07/22/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2022	36 Months From Approved	09/30/2019
Responses	50	0	50
Time Burden (Hours)	38	0	38
Cost Burden (Dollars)	0	0	0

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Abstract: Rules governing the Federal Employee Health Benefits (FEHB) plan require a physician to verify the disability of Federal employees’ children ages 26 and over for these children to retain health benefits under their employed parents’ plans. The physician must verify the adult child’s disability: (1) Pre-dates the child’s 26th birthday; (2) is very serious; and (3) will continue for at least one year. Physicians use Form SSA-604, the Certificate of Incapacity, to document and certify this information, and the Social Security Administration uses the information provided to determine the eligibility for these children, ages 26 and over, for coverage under a parent’s FEHB plan. The respondents are physicians of SSA employees’ children ages 26 or over who are seeking to retain health benefits under their parent’s FEHB coverage.

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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:
	84 FR 18913	05/02/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 34469	07/18/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Certificate of Incapacity	SSA-604	Certificate of Incapacity

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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	50	50	0	0	0	0
Annual Time Burden (Hours)	38	38	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:

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Annual Cost to Federal Government: $6,730

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 07/22/2019

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