Work Activity Report--Employee

Forms and Documents

Document Name	Status
Form SSA-821-BK Work Activity Report--Employee Form	Modified
Addendum to the Supporting Statement 0059.doc Supplementary Document	2015-07-30
Supporting Statement 0059 (Revised).docx Supporting Statement A	2015-07-31

IC Document Collections

IC ID	Document Title	Status
8980	Work Activity Report--Employee Form	Modified

ICR Details

OMB Control No: 0960-0059	ICR Reference No: 201505-0960-008
Status: Historical Active	Previous ICR Reference No: 201204-0960-020
Agency/Subagency: SSA	Agency Tracking No:
Title: Work Activity Report--Employee
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/22/2015
	Date Received in OIRA: 07/31/2015
Terms of Clearance: SSA must report this collection as a violation in the Information Collection Budget unless it show the form was not in use before this reinstatement.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2018	36 Months From Approved
Responses	300,000	0	0
Time Burden (Hours)	150,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Form SSA-821-BK is used by SSA field offices to: obtain work information from recipients' during face-to-face and telephone interviews, or by mail; during the initial claims process, during the continuing disability review process, and whenever a work issues arises in SSI claims. SSA's processing centers Office of Disability and International Operations use the form to obtain post-adjudicative work issue from recipients' by mail. The primary purpose of this form is to collect information concerning whether recipients' have worked in employment after becoming disabled and, if so, whether the work is substantial gainful activity (SGA). SSA will review and evaluate the data to determine if the recipient continues to meet the disability requirement of the law. The respondents are Social Security disability applicants, beneficiaries, and Supplemental Security Income applicants.

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Authorizing Statute(s): US Code: 42 USC 1383b Name of Law: Social Security Act
   US Code: 42 USC 423 Name of Law: Social Security Act
  

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:
	80 FR 29787	05/22/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 43828	07/23/2015
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
Work Activity Report--Employee	SSA-821-BK	Work Activity Report- Employee

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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	300,000	0	0	0	0	300,000
Annual Time Burden (Hours)	150,000	0	0	0	0	150,000
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: $2,310,000

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: 07/31/2015

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