1. State Agency Ticket Assignment Form, 2. State Vocational 3. Individual Work Plans (IWP) Information Sheet

ICR 200110-0960-002

OMB: 0960-0641

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0960-0641 200110-0960-002
Historical Active
SSA
1. State Agency Ticket Assignment Form, 2. State Vocational 3. Individual Work Plans (IWP) Information Sheet
New collection (Request for a new OMB Control Number)   No
Emergency 10/25/2001
Approved without change 12/13/2001
Retrieve Notice of Action (NOA) 10/11/2001
Approved. The burden for this package will be explained in the PRA section of the preamble for the Ticket to Work regulation, along with a listing of sections of the rule that have requirements that are subsumed under this paperwork package.
  Inventory as of this Action Requested Previously Approved
06/30/2002 06/30/2002
31,492 0 0
5,915 0 0
0 0 0

The information collected on forms SSA-1365, SSA-1366 and SSA-1367 will be used to determine proper assignment of Tickets under the program and to monitor services provided by ENs. The information collected on the SSA-1365 will be used by a SSA contracted Program Manager (PM) to perform the task of assigning beneficiaries' tickets and monitoring the use of tickets under this new legislation. SSA-1366 and SSA-1367 will be completed each time a Ticket is assigned to an EN under contract with SSA, or a VRA functioning as an EN.

None
None


No

1
IC Title Form No. Form Name
1. State Agency Ticket Assignment Form, 2. State Vocational 3. Individual Work Plans (IWP) Information Sheet SSA-1365, SSA-1366, SSA-1367

  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 31,492 0 0 31,492 0 0
Annual Time Burden (Hours) 5,915 0 0 5,915 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
10/11/2001


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