Employee Work Activity Questionnaire

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 221, 223(d), 1612(b)(4), and 1614(a)(3) of the Social Security Act, as amended, allow
us to collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent an accurate and timely decision on any claim
filed.
We will use the information you provide to validate unsuccessful work attempts and subsidies,
and to determine benefits eligibility. We may also share the information for the following
purposes, called routine uses:
•

To contractors and other Federal agencies, as necessary, for the purpose of assisting
us in the efficient administration of our programs. We will disclose information
under this routine use only in situations in which we may enter into a contractual or
similar agreement to obtain assistance in accomplishing an SSA function relating to
this system of records, and

•

To claimants, prospective claimants (other than the data subject), and their authorized
representatives or representative payees, to the extent necessary to pursue Social
Security claims; to representative payees, when the information pertains to
individuals for whom they serve as representative payees, for the purpose of assisting
us in administering representative payment responsibilities under the Social Security
Act; and to representative payees, for the purpose of assisting them in performing
their duties as payees, including receiving and accounting for benefits for individuals
for whom they as payees.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0089, Claims Folders System, as published in the Federal Register (FR) on October
31, 2019, at 84 FR 58422; 60-0090, Master Beneficiary Record, as published in the FR on
January 11, 2006, at 71 FR 1826; and 60-0103, Supplemental Security Income Record and
Special Veterans Benefits, at 71 FR 1830. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy.

Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget
(OMB) control number. We estimate that it will take about 15 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.