State Mental Institution Policy Review

Forms and Documents

Document Name	Status
Form SSA-9584-BK State Mental Institution Policy Review Form	Modified
0960-0110 supporting statement.docx Supporting Statement A	2010-12-30
Addendum.doc Supporting Statement B	2010-09-30

IC Document Collections

IC ID	Document Title	Status
9081	State Mental Institution Policy Review Form	Modified

ICR Details

OMB Control No: 0960-0110	ICR Reference No: 201009-0960-005
Status: Historical Active	Previous ICR Reference No: 200712-0960-009
Agency/Subagency: SSA	Agency Tracking No:
Title: State Mental Institution Policy Review
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: 06/08/2011
	Date Received in OIRA: 12/30/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2014	36 Months From Approved	06/30/2011
Responses	88	0	95
Time Burden (Hours)	88	0	95
Cost Burden (Dollars)	0	0	0

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Abstract: The respondents are state mental institutions that serve as representative payees. SSA uses the information collected on SSA-9584 to determine whether an institution's policies and practices conform with SSA's regulations in the use of benefits and payments, and whether the institution is performing other duties and responsibilities required of a representative payee. The information also provides us with the basis for conducting onsite reviews of the institution and preparing subsequent reports of findings. The respondents are state mental institutions serving as representative payees for Social Security beneficiaries and Supplemental Security Income recipients.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: The Public Health and Welfare
   US Code: 42 USC 1383 Name of Law: The Public Health and Welfare
  

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:
	75 FR 59318	09/27/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 80563	12/22/2010
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
State Mental Institution Policy Review	SSA-9584-BK	State Mental Instintution Policy Review

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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	88	95	0	0	-7	0
Annual Time Burden (Hours)	88	95	0	0	-7	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: The number of state institutions participating in the program has declined since we last cleared this information collection.

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Annual Cost to Federal Government: $5,872

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]? 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? 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: 12/30/2010

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