Claimant Travel Reimbursement Request

Forms and Documents

Document Name	Status
Form SSA-104 Claimant Travel Reimbursement Request Form	New
SSA-91--AUTHORIZATION TO RELEASE MEDICAL REPORT TO PHYSICIAN FORM.doc Supplementary Document	2007-06-21
Cover Letter--CE Appointment Notice.doc Supplementary Document	2007-06-21
Supporting Statement--SSA-104.doc Supporting Statement A	2007-06-21
Addendum--SSA-104.doc Supplementary Document	2007-04-16

IC Document Collections

IC ID	Document Title	Status
179637	Claimant Travel Reimbursement Request Form	New

ICR Details

OMB Control No: 0960-0752	ICR Reference No: 200704-0960-011
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Claimant Travel Reimbursement Request
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/20/2007
	Date Received in OIRA: 06/21/2007
Terms of Clearance: This ICR is approved on the understanding that respondents do not have to supply the same information twice (once to state agencies and then again to SSA OMVE), even though the supporting statement suggests otherwise. Rather, at the point in time that this information is being collected, it is either collected by the state DDS (because they are processing the case) or it is collected by OMVE (because we are processing the case), not by both.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2010	36 Months From Approved
Responses	11,092	0	0
Time Burden (Hours)	1,849	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The claimants have the right to be reimbursed for their travel expenses to and from a consultative examination (CE). In order to be reimbursed, the claimants must submit an itemized list of what they spent to travel round trip to the CE. The SSA-104 is sent to the claimants with the CE appointment notice. If the claimants want to be reimbursed for their travel expenses, they must complete, sign and return the SSA-104 to SSA. SSA uses the information collected on this form to determine the amount of reimbursement. Respondents are applicants for disability claims.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

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 28540	05/21/2007
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Claimant Travel Reimbursement Request	SSA-104	Claimant Travel Reimbursement Request

---

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	11,092	0	0	11,092	0	0
Annual Time Burden (Hours)	1,849	0	0	1,849	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is an information collection in use without an OMB control number that will increase the public reporting burden.

---

Annual Cost to Federal Government: $17,082

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

---

Common Form ICR:  No

---

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: 06/21/2007

---