Employee Work Activity Questionnaire

Forms and Documents

Document Name	Status
Form SSA-3033 Employee Work Activity Questionnaire Form and Instruction	Modified
Non-Substantive Change request for SSA-3033.doc Justification for No Material/Nonsubstantive Change	2014-07-22

IC Document Collections

IC ID	Document Title	Status
9380	Employee Work Activity Questionnaire Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0483	ICR Reference No: 201407-0960-012
Status: Historical Active	Previous ICR Reference No: 201311-0960-011
Agency/Subagency: SSA	Agency Tracking No:
Title: Employee Work Activity Questionnaire
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/23/2014
	Date Received in OIRA: 07/23/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	06/30/2017	06/30/2017
Responses	15,000	0	15,000
Time Burden (Hours)	3,750	0	3,750
Cost Burden (Dollars)	0	0	0

---

Abstract: Social Security disability claimants qualify for benefits when a verified physical or mental impairment prevents them from working. If disability claimants attempt to return to work after receiving disability benefits but are unable to continue working, employers submit Form SSA-3033, the Employee Work Activity Questionnaire, so SSA can evaluate the work attempt. SSA also uses this form to evaluate unsuccessful subsidy work. Ultimately, SSA uses the form to determine applicants' continuing eligibility for disability benefits. The respondents are employers of Social Security disability beneficiaries who unsuccessfully attempted to return to work. We are adding the beneficiary's Social Security Number (SSN) on every page of Form SSA-3033.

---

Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 1382a Name of Law: Social Security Act
   US Code: 42 USC 1382c Name of Law: Social Security Act
   US Code: 42 USC 421 Name of Law: Social Security Act
  

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:
	78 FR 76378	12/17/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 13368	03/10/2014
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
Employee Work Activity Questionnaire	SSA-3033	Work Activity Questionnaire

---

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	15,000	15,000	0	0	0	0
Annual Time Burden (Hours)	3,750	3,750	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:

---

Annual Cost to Federal Government: $46,200

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

---

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: 07/23/2014

---