Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits

Forms and Documents

Document Name	Status
Form SSA-787 Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits Form	Modified
Addendum--0024.doc Supplementary Document	2007-03-12
Supporting Statement--0024.doc Supporting Statement A	2007-04-24

IC Document Collections

IC ID	Document Title	Status
8918	Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits Form	Modified

ICR Details

OMB Control No: 0960-0024	ICR Reference No: 200703-0960-004
Status: Historical Active	Previous ICR Reference No: 200404-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits
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: 08/02/2007
	Date Received in OIRA: 05/07/2007
Terms of Clearance: This ICR is approved for 2 years only. Upon resubmission, SSA will explore the feasibility of providing physicians and medical officers an electronic version of this form, particularly in light of the direction towards electronic records that SSA is moving towards. Though a fully-downloadable form may not be feasible due to privacy and fraud concerns, SSA should nevertheless consider creating something like a fillable PDF form, which SSA can send directly to respondents and which respondents may find more useful than a paper form.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2009	36 Months From Approved	08/31/2007
Responses	120,000	0	120,000
Time Burden (Hours)	20,000	0	20,000
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected on the SSA-787 is used to determine whether an individual is capable of handling his or her own benefits. This information is also used for leads in selecting a representative payee, if needed. The respondents are physicians of the beneficiaries or medical officers of the institution in which the beneficiaries reside.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: null
   US Code: 42 USC 1383 Name of Law: null
  

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:
	72 FR 7107	02/14/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 20154	04/23/2007
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
Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits	SSA-787	Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits

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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	120,000	120,000	0	0	0	0
Annual Time Burden (Hours)	20,000	20,000	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: $184,800

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

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: 05/07/2007

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