Work Activity Report--Employee

Forms and Documents

Document Name	Status
Form SSA-821-BK Work Activity Report--Employee Form	Modified
Justification for Non-Substantive Changes - 0059 (IT Mod Change Request).docx Justification for No Material/Nonsubstantive Change	2021-06-29
Supporting Statement - 0059.docx Supporting Statement A	2018-10-08

IC Document Collections

IC ID	Document Title	Status
8980	Work Activity Report--Employee Form	Modified

ICR Details

OMB Control No: 0960-0059	ICR Reference No: 202106-0960-006
Status: Received in OIRA	Previous ICR Reference No: 202008-0960-020
Agency/Subagency: SSA	Agency Tracking No:
Title: Work Activity Report--Employee
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/29/2021

	Requested	Previously Approved
Expiration Date	12/31/2021	12/31/2021
Responses	300,000	300,000
Time Burden (Hours)	150,000	150,000
Cost Burden (Dollars)	0	0

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Abstract: SSA uses Form SSA-821-BK to collect employment information to determine whether individuals have worked after becoming disabled and, if so, whether the work is SGA. We use the information to make a determination of eligibility for disability payments. Specifically, we use Form SSA-821-BK to obtain information from individuals during the initial SSI and SSDI claims process; the Continuing Disability Review (CDR) process; and appeals involving work issues. An SSA employee may fill out the form during an in office or telephone interview, or the applicants or recipients may fill it out themselves. SSA reviews and evaluates the data to determine if the applicant or recipient meets the disability requirements of the law. If respondents work when they apply for benefits, they must complete this collection to obtain SSI or SSDI. The respondents are SSDI applicants or recipients, and SSI applicants. This is a Non-Substantive IT Mod Change Request to include a submittable PDF under this ICR.

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Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 1383b 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:
	83 FR 31987	07/10/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 49965	10/03/2018
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
Work Activity Report--Employee	SSA-821-BK, eSSA-821	Work Activity Report- Employee ,   Work Activity Report- Employee

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ICR Summary of Burden

	Total Request	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	300,000	300,000	0	0	0	0
Annual Time Burden (Hours)	150,000	150,000	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: $232,000

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? No

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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: 06/29/2021

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