Request for Non-Substantive Changes
Revision to the Collection Instrument:
We are making revisions to clarify the language, remove questions, and streamline the form to make it easier for respondents to use. We anticipate these actions will decrease the burden hours for this form.
The last time we submitted this collection, we reported approximately 300,000 respondents take 45 minutes each to complete form SSA-821-BK each year for a total estimated burden of 225,000 hours. Based on these new revisions, we estimate the respondents will take 40 minutes each to complete the form for a burden of 200,000 hours. This represents a five-minute decrease in burden per respondent.
The revisions to the collection instrument are as follows:
Change 1: We re-wrote the entire cover letter. We included contact information, which is inclusive of international offices. We inserted the claimant or beneficiary’s salutation information. We followed the electronic format of the cover letter that housed in the eWork system. We provided employer information. We provided an online link to access the “Working While Disabled-How We Can Help,” pamphlet. We changed the enclosures to include either the SSA-821-BK or the SSA-820-F4.
Justification 1: We re-wrote the cover letter in plain language for clarity. We worked with SSA’s Office of Open Government to help conform to agency notice language standards. In addition, we re-arranged the order of the sentences for organizational purposes. We changed the enclosure language because we could be sending either form or both forms.
Change 2: We inserted the claim number at the top right-hand of the form.
Justification 2: To protect the personally identifiable information of beneficiaries and claimants, and to avoid human error in case processing, we inserted the SSN on each page of the form.
Identification-To Be Completed by SSA section:
Change 3: We bolded and shaded the “Identification-To Be Completed by SSA” section.
Justification3: To assist the user by visually distinguishing the headers from the body of the form.
Change 4: We inserted the word “OWN” in the Claimant or Beneficiary’s SSN block.
Justification 4: To ensure user wrote the correct SSN, which avoids adjudicative errors.
Change 5: We changed format of “Blind and Not Blind” boxes.
Justification 5: We changed the format to a linear style to visually balance the reader; this was a recommendation from SSA’s Usability Center.
Change 6: We removed “Name of Wage Earner (if different from Claimant or Beneficiary) and The Wage Earners SSN,” and replaced it with “Claim Number & BIC”
Justification 6: We changed language to match a claims representative’s mental model and vocabulary.
Change 7: We removed the information pertaining to what benefits the claimant or beneficiary is receiving.
Justification 7: We do not need this information on the form itself since we provide this information on the cover letter, and this information is accessible to SSA staff in electronic records.
Change 8: We deleted “Part I –To Be Completed By SSA” and moved the information in that Part 1 to the identification section.
Justification 8: Changes made due to organizational purposes.
Change 9: We changed the sentence, made fonts bold, and added a boarder date box to insert the date:
Old Language: “Please use this form to tell us about your work since….”
New Language: “Please use this form to tell us about your work activity since (Insert alleged onset date, date of onset, date of entitlement, or last determination date, as appropriate).”
Justification 9: We re-wrote this sentence for clarity, and we provided examples of what date to insert for SSA staff so that he or she can correctly identify the date requested. We bolded and darkened the date box to make the field stand out visually.
Information - To Be Completed By Person Applying For Or Receiving Benefits:
Change 10: We changed the language, and made some language bold.
Old Language: “ANSWER THE QUESTIONS ON THIS FORM AND RETURN IT AND ANY OTHER INFORMATION ABOUT YOUR CLAIM TO THE SOCIAL SECURITY OFFICE THAT GAVE (OR SENT) YOU THE FORM”
New Language: “Please answer each of the questions on this form with as many details as you can. This information will help us decide if you should get or keep getting disability benefits. If you need more room for your answers, go to the Remarks Section at the end of the form.”
Justification 10: We made these changes to support the Commissioner’s suggestion to ask for information politely, and we wanted to give direct instructions. We also bolded and re-structured the sentence for visual aid, and correct grammatical structure. We provided the option to include additional information in the Remarks section for easier use.
Change 11: We deleted “PART II TO BE COMPLETED BY SSA,” and created the section called “Information-To Be Completed By Person Applying For Or Receiving Benefits.” We shaded the section and bolded the words.
Justification 11: We made these changes to visually distinguish the header from the content of the form.
Change 12: We re-wrote the following sentence in upper and lower case, and we bolded specific words. We changed the direction for the “yes” box to direct the user to question 2, and if the “no” box is answered; the user is directed to question 3.
Old Language: “Have you worked since the date shown in item 1 of part 1, above?”
New Language: “Have you had any employment income or wages since the DATE shown above in the identification section? (check one).”
Justification 12: We changed the language for clarity. We bolded words to highlight the importance of the date in question. We changed the instructions when checking yes or no for organizational purposes.
Change 13: We reformatted question 2, and inserted a chart with examples of other types of income. We provided a specific example. We informed the public that we may request proof of this type of income. We requested the name and address of the payer, the amount of the payment, and date they received payment. We direct the user to question 7 if the individual did not work.
Justification 13: We reorganized and formatted this question for future electronic process. We added check boxes so that when the form becomes electronic, these boxes will become “drop-down” boxes. We rewrote the question so the claims representative can determine a correct dollar amount to exclude from the substantial gainful activity decision. We are informing the public we may request proof of payment to prepare them for the potential recontact. To save time and work effort, if the respondents did not work, we are directing them to question 7.
Change 14: We re-titled “3” to “3A”. We changed the sentence from “TELL US ABOUT YOUR WORK SINCE THE DATE IN ITEM 1 OF PART 1 ABOVE” to read: “Please tell us about your work since the DATE shown in the Identification section, beginning with your most recent employer. If you are not sure about this, ask your employer(s) to help you. Use the additional space provided in the Remarks section if you need more room for your answer.” In addition, we bolded words, and capitalized the word date, and we direct the user to document additional employers in the Remarks section, as opposed to “item 9”.
Justification 14: We re-wrote the sentence for politeness and clarity, and bolded words for consistency within the form. We directed the user to the remarks sections so that they will not have to think about where “item 9” is located.
Change 15: We changed the language as follows:
Old Language: “Employers Name”
New Language: “Current or Most Recent Employer’s Name”
Justification 15: We re-worded the instruction for clarity and consistency within the form.
Change 16: We inserted a space for area code telephone and fax number.
Justification 16: This provides the claims representative an additional method of contact.
Change 17: We changed the Employers address field to separate out the mailing address, city, state, and zip.
Justification 17: This change provides consistency throughout the form and helps the user visually see that each is a separate section.
Change 18: We inserted a “Job Title & Type of Work” field.
Justification 18: This is consistent with the development that a claims representative needs to develop and process his or her decision.
Change 19: We changed the format and organization of the fields that request when the date work started, work ended, the starting salary, and number of hours worked. We inserted a field for “still working,” and re-organized location of fields.
Justification 19: We made these changes to enhance organization of the form, and to help the user visually see what we are asking them to complete. The Usability Center recommended these changes based on responses they received from the individuals they tested.
Change 20: We deleted the supervisor’s name and telephone number.
Justification 20: We no longer need this information. Supervisors can change frequently, and as long as we have the company’s telephone number, and address, we will be able to develop the information.
Change 21: We moved the information pertaining to unsuccessful work attempts (“I stopped working within 6 months, or I reduced my hours…”) from this area of the form, to question 6A of the revised form. We changed the language, re-formatted the question, and asked for the employer name, date, and a description of the change. We deleted the language “I stopped working within 6 months.”
Justification 21: We deleted the time frame of “6 months” because this concept confuses the public. This concept is internal to SSA employees for processing work activity. We provided a chart format for organization and to establish the format for the future electronic process. We are requesting additional information, such as the name of the employer and the date of the change so the claims representative can make an accurate determination. We wanted the user to understand the question, and have a visual cue on where to place his or her answers.
Change 22: We moved question 4 to question 3. We rewrote the question, and asked that the individual provide pay stubs or gross wage printouts for each employer. We deleted the numerical amount of earnings “$200 per month through 12/2000…”
Justification 22: We moved question 4 for organizational purposes. We re-wrote the question for clarity. The proofs we are requesting are necessary for the development of the claim. Since we are requesting proofs with the form, this will alleviate the potential of re-contacting the individual. We deleted the numerical amounts to keep the form current. We also want to avoid placing an undue burden on the public, as they would have to make unnecessary calculations.
Change 23: We rewrote, reformatted, and reorganized question 5. We shaded the headers, changed the alignment of the words, and the layout of the table. We provided additional space for answers, and inserted “other,” and “none of the above apply” options.
Justification 23: We inserted an organizational chart to make the form visually appealing and easier for the user to read. To assist the user in understanding and answering the questions, we helped the users associate the example text with the spaces we provided. To assist claims representatives in making determinations, we asked for the employer name and date. We provided additional space for answers so the user does not have to go to the Remarks section.
Change 24: We re-wrote, re-organized, and re-formatted question 6A. We shaded the header, provided an additional option to state that the individual did not have changes, and provided the individual an opportunity to abort and sign the forms.
Justification 24: We rewrote this question for clarity and for visual appeal. We changed the layout of the chart to help the users understand the question and understand what we expect of them when answering the question.
Change 25: We created a new question 6B.
Justification 25: We are providing the user additional space that relates to his or her work changes so that he or she will not have to write additional responses in the Remarks section.
Change 26: We re-wrote, re-organized, and re-formatted question 7. We bolded pertinent words, we shaded the header. We provided another example of an IRWE (co-pays). We advised we might need proof of payment. We provided an example. We modified the chart. We deleted “special transportation,” “cost,” “modified vehicle,” and “taxi-type service.”
Justification 26: We re-wrote this question to provide clarity and to help the user understand what we are asking of him or her. We bolded “related to your physical and/or mental condition(s)” so the reader’s eyes are drawn to the importance of the words, increasing readability. We provided an example to ensure understanding. We deleted elements of the sentence that were confusing to the reader. We are advising the reader we may ask for proof of payment to prepare him or her for a re-contact, therefore, providing good customer service.
Change 27: We replaced item 9 with a “Remarks section,” and added the language “Use this section to add any information you did not have space for in other parts of the form. Please show the number of the question you are answering.”
Justification 27: We created a section in lieu of an “item 9” to support consistency and organization throughout the form. We wrote the question in plain language, and we provide concise instructions for the user.
Change 28: We moved question 10 to the Signature Section. We made the signature section bold. We did not change the content of the question.
Justification 28: We moved this question into its own section for organizational purposes.
Change 29: We are deleting page 8, “FOR SSA USE ONLY-DO NOT WRITE ON THIS PAGE”
Justification 29: We created a new SGA determination form, the SSA-823, which will capture this information.
NOTE: We will use the revised form as soon as we make it available in the eWork and eForm system. We will destroy the old versions of this form.
| File Type | application/msword |
| Author | 889123 |
| Last Modified By | 889123 |
| File Modified | 2011-03-31 |
| File Created | 2011-03-31 |