Non-Substantice Change Request

Justification for Non-Substantive Changes to

Form SSA-821-BK: Work Activity Report – Employee

20 CFR 404.1520(b), 404.1571-404.1576,

404.1584-404.1593, and 416.971-416.976

OMB No. 0960-0059

Background

The Social Security Administration (SSA) uses Form SSA-821-BK to collect employment information to determine whether individuals worked after becoming disabled and, if so, whether the work is substantial gainful activity (SGA). We use the information to make a determination of eligibility for disability payments. Specifically, we use Form SSA-821-BK to obtain information from individuals to evaluate initial Supplemental Security Income (SSI) and Social appeals that involve work issues.

While we still accept, and will continue to accept, paper versions of the SSA-821-BK, we created an online fillable and submittable version titled SSA-821-APP, which utilizes Adobe Sign technology to accept and process an electronic signature (eSignature). The online version of the SSA-821-APP mirrors the paper version and provides respondents with an online service option as an alternative to mailing or faxing the form to the servicing office. Respondents will be able to initiate the online version from our website and electronically complete, sign, and submit it using the Adobe Sign web application. Use of the Adobe Sign web application does not present any added burden on respondents. Respondents will not be required to download and install the application locally on their device, nor will they have to pay any subscription or licensing fees.

With this new modality for submission, respondents will enter their responses into structured data fields on the online SSA-821-APP screens within the Adobe platform by following a secure link that Adobe Sign sends to the email address the respondent provides. The respondent will receive an email from Adobe Sign with a secure link to the form and instructions for how to complete, electronically sign (eSign), and submit the form using this online service. Upon submission, the online SSA-821-APP electronically transmits an image of the completed form to SSA’s WorkTrack application for processing by the servicing office. The servicing office will review the information and follow policies and procedures to make the SGA determination.

To protect the respondent’s privacy, the respondent will create a password to protect access to the form. To view the completed form, the respondent will need to enter their password correctly before obtaining access to the information. The Adobe Sign platform will provide a copy of the completed form to the respondent via a password-protected link in an email. Finally, each session will time-out after 60 minutes of inactivity. The respondent will need to use the link to re-enter the form, enter their password, and then continue completing the submittable version. The submittable SSA-821-APP will be available to the respondent for fifteen (15) calendar days via the email link, during which time Adobe Sign will send email reminders every three days to ensure timely submission. After those fifteen (15) days, the link will expire, and the respondent will need to re-initiate the process by entering his or her email on the form’s website to receive a new email link to a blank form.

We are submitting this IT Modification as a non-substantive change request to create a submittable Portable Document Format (PDF) for Form SSA-821-APP, Work Activity Report – Employee which mirrors the current paper form. We intend to implement this submittable PDF on July 31, 2021

Revisions to the Collection Instrument for the Online Modality

• Change #1: On the first screen for the online SSA-821-APP, the respondent must read and acknowledge instructions and the Privacy Act (PA) Statement associated with the SSA-821-APP.

Justification: The instructions provide key information to the respondent about the Adobe Sign process, as described in the above background information.

• Change #2: The second screen requires the respondent to enter and confirm their email address and to establish and confirm a password.

Justification: Once the respondent submits the email address and creates a password, they will receive an email from Adobe Sign with a secure link to complete the form electronically.

• Change #3: We revised the first two pages of the form from a two-page notice to a one-page information cover sheet.

Justification: Currently, we mail the SSA-821-BK to our customers and the first two pages of the form include a cover notice for the mailed form that includes personally identifiable information (PII) from our records. Most respondents using the online modality will have received a paper form in the mail that they reference as they complete the online form. The form’s online landing page includes instructions on where to find the information that would normally be included in the mailed cover notice.

• Change #4: We updated the “Identification” section to remove “To Be Completed by SSA” and replaced the “BNC#” field with an “SSN” field.

Justification: In the online modality, the respondent will complete the fields in the “Identification” section. Customers may not know the Beneficiary Notice Control number (BNC#) to use, as SSA creates each BNC# specifically for the notice being mailed. In the current paper process, the BNC# is pre-filled by our system on each printed notice. Customers know their Social Security number (SSN) and can complete that field without assistance. Using the SSN also saves time when we receive the submitted online form, as correlating the BNC# to the SSN will require additional technical solutions to process the incoming form.

• Change #5: Respondents will have the option to attach documents such as paystubs.

Justification: For paper forms, respondents usually mail in evidentiary documents to support their statements on the form. The attachment feature will allow respondents to attach those documents instead of mailing them to SSA and waiting for the agency to return them.

• Change #6: We are revising the PA Statement on this form.

Justification #6: SSA’s Office of the General Counsel, Office of Privacy and Disclosure is conducting a systematic review of SSA’s PA Statements on agency forms consistent with our Privacy Continuous Monitoring Strategy. As a result, SSA is updating the PA Statement on this form to align with current requirements and guidance.

SSA will implement the online SSA-821-APP upon the Office of Management and Budget’s (OMB) approval. Since we are not requiring any additional information, we are making no substantive changes to the content of the SSA-821-APP other than to adapting it to the new electronic submission method, including minor corresponding revisions to the instructions only; we expect no change in the current burden information for this collection.

We intend to implement the submittable PDF modality by July 31, 2021. Therefore, we are asking OMB to approve this IT Modification request as soon as possible so we can meet our implementation date.

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