State Mental Institution Policy Review

Forms and Documents

Document Name	Status
Form SSA-9584-BK State Mental Institution Policy Review Form	Modified
Addendum - 0110.docx Supplementary Document	2017-03-29
Supporting Statement - 0110.docx Supporting Statement A	2017-03-29

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: 201701-0960-001
Status: Active	Previous ICR Reference No: 201311-0960-010
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 with change	Conclusion Date: 09/29/2017
	Date Received in OIRA: 04/28/2017
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2020	36 Months From Approved	09/30/2017
Responses	69	0	78
Time Burden (Hours)	69	0	78
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:
	82 FR 3838	01/12/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 15412	03/28/2017
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	69	78	0	-9	0	0
Annual Time Burden (Hours)	69	78	0	-9	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The decrease in burden hours stems from a decline in the number of State institutions participating in the onsite review program.

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Annual Cost to Federal Government: $1,100

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 04/28/2017

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