Daily Rules, Proposed Rules, and Notices of the Federal Government


Agency Information Collection Activities: Proposed Request and Comment Request

The Social Security Administration (SSA) publishes a list of information collection packages requiring clearance by the Office of Management and Budget (OMB) in compliance with Public Law 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. This notice includes revisions to and one extension of OMB-approved information collections.

SSA is soliciting comments on the accuracy of the agency's burden estimate; the need for the information; its practical utility; ways to enhance its quality, utility, and clarity; and ways to minimize burden on respondents, including the use of automated collection techniques or other forms of information technology. Mail, email, or fax your comments and recommendations on the information collection(s) to the OMB Desk Officer and SSA Reports Clearance Director at the following addresses or fax numbers.


Office of Management and Budget, Attn: Desk Officer for SSA, Fax: 202-395-6974, Email


Social Security Administration, DCRDP, Attn: Reports Clearance Director, 107 Altmeyer Building, 6401 Security Blvd., Baltimore, MD 21235, Fax: 410-966-2830, Email

I. The information collections below are pending at SSA. SSA will submit them to OMB within 60 days from the date of this notice. To be sure we consider your comments, we must receive them no later than October 9, 2012. Individuals can obtain copies of the collection instruments by writing to the above email address.

1.Employment Relationship Questionnaire--20 CFR 404.1007--0960-0040.When SSA needs information to determine a worker's employment status for the purpose of maintaining a worker's earning records, the agency uses Form SSA-7160-F4 to determine the existence of an employer-employee relationship. We use the information to document the employment relationship; specifically, to determine whether a beneficiary is self-employed or an employee. The respondents are individuals seeking to establish their status as employees and their alleged employers.

Type of Request: Revision of an OMB-approved information collection.

2.Blood Donor Locator Service (BDLS)--20 CFR 401.200--0960-0501.The regulations on Privacy and Disclosure of Official Records and Information, Subpart C, stipulate that when blood donor facilities identify blood donations as human immunodeficiency virus (HIV)-positive, the overseeing state agency must provide the names and Social Security Numbers of the affected donors to SSA's Blood Donor Locator Service. SSA uses this information to furnish the state agencies with the blood donors' address information to notify the blood donors. Respondents are state agencies acting on behalf of blood donor facilities.

Type of Request.Extension of an OMB-approved information collection.

3.The Ticket to Work and Self-Sufficiency Program--20 CFR 411--0960-0644.SSA's Ticket to Work (Ticket) Program transitions Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) recipients toward independence by allowing them to receive Social Security payments while maintaining employment under the auspices of the program. SSA uses service providers, called Employment Networks (ENs), to supervise participant progress through the stages of Ticket Program participation, such as job searches and interviews, progress reviews, and changes in ticket status. ENs can be private for-profit and nonprofit organizations, as well as state vocational rehabilitation agencies (VRs).

SSA and the ENs utilize the Ticket to Work Program Manager to operate the Ticket Program and exchange information about participants. For example, the ENs use the Program Manager to provide updates on tasks such as selecting a payment system or requesting payments for helping the beneficiary achieve certain work goals.

Since the ENs are not PRA-exempt, the multiple information collections within the Ticket Program Manager require OMB approval, and we clear them under this information collection request (ICR). Most of the categories of information in this ICR are necessary for SSA to: (1) Comply with the Ticket to Work legislation; and (2) provide proper oversight of the program. SSA collects this information through several modalities, including forms, electronic exchanges, and written documentation. The respondents are the ENs or state VRs, as well as SSDI beneficiaries and blind or disabled SSI recipients working under the auspices of the Ticket to Work Program.

Type of Request:Revision of an OMB-approved information collection.

II. SSA submitted the information collection below to OMB for clearance. Your comments regarding the information collection would be most useful if OMB and SSA receive them within 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than September 10, 2012. Individuals can obtain copies of the OMB clearance package by writing

Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare)--0960-0729.Under the aegis of the Medicare Modernization Act of 2003, Medicare beneficiaries can apply for a Medicare Prescription Drug Plan (Part D) program subsidy. In some cases, SSA will verify the details of applicants' accounts at financial institutions to determine if they are eligible for the subsidy. Form SSA-4640 provides the applicant authorization SSA needs to contact financial institutions about applicants' accounts. Financial institutions use the form to verify the information SSA requests. The respondents are applicants for the Medicare Part D program subsidy, and financial institutions where these applicants are account holders.

Type of Request:Revision of an OMB-approved information collection.

Dated: August 7, 2012. Faye Lipsky, Reports Clearance Director, Social Security Administration.