Response to Notice of Revised Determination

Forms and Documents

Document Name	Status
Form SSA-765 Response to Notice of Revised Determination Form and Instruction	Modified
Supporting Statement - 0347.docx Supporting Statement A	2015-11-27

IC Document Collections

IC ID	Document Title	Status
9225	Response to Notice of Revised Determination Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0347	ICR Reference No: 201510-0960-005
Status: Historical Active	Previous ICR Reference No: 201210-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Response to Notice of Revised Determination
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/05/2016
	Date Received in OIRA: 11/27/2015
Terms of Clearance: This collection is approved based on the revised materials provided by the Agency.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2019	36 Months From Approved	02/29/2016
Responses	1,925	0	1,925
Time Burden (Hours)	963	0	963
Cost Burden (Dollars)	0	0	0

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Abstract: When SSA determines that 1) claimants for initial disability benefits do not actually have a disability or 2) current records indicate the disability recipients' disability ceased, SSA notifies the disability claimants/recipients of this decision. In response to this notice, the affected claimants and disability recipients have the following recourse: 1) they may request a disability hearing to contest SSA's decision and 2) they may submit additional information or evidence for SSA to consider. Disability claimants, recipients, and their representatives use Form SSA-765, the Response to Notice of Revised Determination, to accomplish these two actions. The respondents are disability claimants, current disability recipients, or their representatives.

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Authorizing Statute(s): US Code: 42 USC 405 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 51647	08/25/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 66967	10/30/2015
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
Response to Notice of Revised Determination	SSA-765	Response to Notice of Revised Determination

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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	1,925	1,925	0	0	0	0
Annual Time Burden (Hours)	963	963	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: $2,965

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: 11/27/2015

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