Medical Source Opinion of Patient’s Capability to Manage Benefits

Forms and Documents

Document Name	Status
Form SSA-787 Medical Source Opinion of Patient's Capability to Manage Benefits Form	Modified
Addendum - 0024.docx Supplementary Document	2018-10-03
Supporting Statement - 0024.docx Supporting Statement A	2018-10-03

IC Document Collections

IC ID	Document Title	Status
8918	Medical Source Opinion of Patient's Capability to Manage Benefits Form	Modified

ICR Details

OMB Control No: 0960-0024	ICR Reference No: 201805-0960-015
Status: Active	Previous ICR Reference No: 201511-0960-013
Agency/Subagency: SSA	Agency Tracking No:
Title: Medical Source Opinion of Patient’s Capability to Manage Benefits
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: 12/10/2018
	Date Received in OIRA: 10/08/2018
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	12/31/2021	36 Months From Approved	12/31/2018
Responses	131,556	0	120,000
Time Burden (Hours)	43,852	0	20,000
Cost Burden (Dollars)	0	0	0

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Abstract: SSA collects medical evidence on Form SSA-787 to: (1) determine beneficiaries’ capability or inability to handle their own benefits; and (2) assist in determining the beneficiaries’ need for a representative payee. The respondents are the beneficiary’s physicians or medical officers of the institution in which the beneficiary resides.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 1383 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:
	83 FR 31987	07/10/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 49965	10/03/2018
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
Medical Source Opinion of Patient's Capability to Manage Benefits	SSA-787	Medical Source Opinion of Patient’s Capability to Manage Benefits

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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	131,556	120,000	0	0	11,556	0
Annual Time Burden (Hours)	43,852	20,000	0	0	23,852	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 change stems from an increase in the number of respondents from 120,000 to 131,556. In addition, the completion time raised from 10 to 20 minutes. We increased the number of questions to improve the quality of information collected through this instrument.

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Annual Cost to Federal Government: $184,800

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: 10/08/2018

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