Supporting Staement - 0347 (Final)

Supporting Statement for Form SSA-765

Response to Notice of Revised Determination

20 CFR 404.913-404.914, 404.992(b), 416.1413-416.1414, and 416.1492(d)

OMB No. 0960-0347

1. Justification

1. Introduction/Authoring Laws and Regulations

When the Social Security Administration (SSA) revises a reconsidered determination that a claimant is disabled, based on medical factors, SSA notifies the disability recipients of this proposed revision. In response to this notice, the disability recipients have the following recourse: (1) they may request a disability hearing to contest SSA’s determination, and (2) they may submit additional information or evidence for SSA to consider prior to the issuance of the revised reconsidered determination. The legal authority governing these actions is the Social Security Act, sections 205(a) and 1631(e)(1)(A); and the Code of Federal Regulations, Sections 20 CFR 404.913‑404.914; 416.1413-416.1414; 404.992(b); and 416.1492(d). Disability recipients and their representatives use Form SSA‑765, the Response to Notice of Revised Determination, to accomplish these two actions.

2. Description of Collection

When SSA determines: (1) claimants for initial disability benefits do not actually have a disability; or (2) current disability recipients’ records show their disability ceased, SSA notifies the disability claimants, or recipients of this decision. In response to this notice, the affected claimants and disability recipients have the following recourse: (1) they may request a disability hearing to contest SSA’s decision; and (2) they may submit additional information or evidence for SSA to consider. Disability claimants, recipients, and their representatives use Form SSA-765 to accomplish these two actions. If respondents request the first option, SSA’s Disability Hearings Unit uses the form to schedule a hearing; ensure an interpreter is present, if required; and ensure the disability recipients or claimants, and their representatives, receive a notice about the place and time of the hearing. If respondents choose the second option, SSA uses the form and other evidence to reevaluate the claimant’s or recipients’ case and determine if the new information or evidence will change SSA’s decision. The respondents are disability claimants, current disability recipients, or their representatives.

3. Use of Information Technology to Collect the Information

Disability recipients, or their representatives, can complete the paper SSA-765, or they can download and complete the fillable PDF version of the form from our website. In either case, the respondents using the paper or fillable PDF version needs to complete the form, and submit it to SSA either via USPS mail, or by bringing the completed form to an SSA field office. Once SSA receives the paper SSA-765, and any supplemental information if necessary, we process the information and store it in EDCS.

This collection does not currently have a fully public-facing Internet version, as we prioritized other information collections for full electronic conversions. Given that IT Mod programming is an ongoing, dynamic project, we cannot provide specific timelines for when we will be able to make any particular ICR available via Internet web-based application.  We will ultimately convert most existing ICRs to full electronic versions depending on how they fall within our overall IT Mod schema, but this may be unconnected to the PRA approval lifecycle.  In the interim, we evaluated this collection for conversion to a submittable PDF and intend to make this conversion within the next 3-6 years. Once we have the submittable PDF ready for implementation, we will submit a Change Request to OMB for prior approval.

4. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it preclude duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently

If SSA did not conduct this information collection, current disability recipients

whose determinations are revised would have no means of requesting a hearing or submitting additional information, which would be a violation of the regulations cited in #1 above. Because SSA only collects this information under the circumstances mentioned above, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on November 30, 2021, at 86 FR 68034, and we received no public comments. The 30-day FRN published on February 7, 2022 at 87 FR 6929. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the revision this form.

9. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

10. Assurance of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

11. Justification for Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollars)*	Average Wait Time in Field Office (minutes)**	Total Annual Opportunity Cost (dollars) ***
SSA-765	51	1	30	26	$19.01*	24**	$874***

* We based this figure by averaging both the average DI payments based on SSA's current FY 2021 data (https://www.ssa.gov/legislation/2021FactSheet.pdf), and the average U.S. worker’s hourly wages, as reported by Bureau of Labor Statistics data (https://www.bls.gov/oes/current/oes_nat.htm).

** We based this figure on averaging both the average FY 2021 wait times for field offices and teleservice centers, based on SSA’s current management information data.

*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

In addition, OMB’s Office of Information and Regulatory Affairs (OIRA) is requiring SSA to use a rough estimate of a 30-minute, one-way, drive time in our calculations of the time burden for this collection. OIRA based their estimation on a spatial analysis of SSA’s current field office locations and the location of the average population centers based on census tract information, which likely represents a 13.97 mile driving distance for one-way travel. We depict this on the chart below:

Total Number of Respondents Who Visit a Field Office	Frequency of Response	Average One-Way Travel Time to a Field Office (minutes)	Estimated Total Travel Time to a Field Office (hours)	Total Annual Opportunity Cost for Travel Time (dollars)*
51	1	30	26	$285

*We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

Per OIRA, we include this travel time burden estimate under the

5 CFR 1320.8(a)(4), which requires us to provide “time, effort, or financial resources expended by persons [for]…transmitting, or otherwise disclosing the information,” as well as 5 CFR 1320.8(b)(3)(iii) which requires us to estimate “the average burden collection…to the extent practicable.” SSA notes that we do not obtain or maintain any data on travel times to a field office, nor do we have any data, which shows that the average respondent drives to a field office, rather than using any other mode of transport.

SSA also acknowledges that respondents’ mode of travel and, therefore, travel times vary widely dependent on region, mode of travel, and actual proximity to a field office.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection.  Per our management information data, we believe that 30 minutes accurately shows the average burden per response for reading the instructions, gathering the facts, and answering the questions.  Based on our current management information data, the current burden information we provided is accurate.  The total burden for this collection instrument is 71 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $1,159.  SSA does not charge respondents to complete our applications.

13. Annual Cost to the Respondent

This collection does not impose a known cost burden on the respondents.

14. Annual Cost to the Federal Government

The annual cost to the Federal Government is approximately $4,313. This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars*
Designing and Printing the Form	Design Cost + Printing Cost	$380
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$0*
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$513
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0*
Systems Development, Updating, and Maintenance	GS-9 employee x man hours for development, updating, maintenance	$3,420
Quantifiable IT Costs	Any additional IT costs	$0*
Total		$4,313

* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have. First, since we work with almost every US citizen, we often do bulk mailings, and cannot track the cost for a single mailing.  In addition, it is difficult for us to break down the cost for processing a single form, as field office staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent.  As well, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average claims representative (GS-11) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection Request

When we last cleared this IC in 2019, the burden was 963 hours. However, we are currently reporting a burden of 26 hours. This change stems a decrease increase in the number of responses from 1,925 to 963. This decrease stems from fewer respondents completing Form SSA-765. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data.

* Note:  The total burden reflected in ROCIS is 2,695, while the burden cited in #12 above is 26. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a

30-minute, one-way, drive burden. In contrast, the chart in #12 above reflects actual burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of this information collection.

17. Displaying the OMB Approval Expiration Date

For the paper Form SSA-765, we will not publish the OMB approval expiration date. OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

18. Exception to Certification Statement

SSA is not requesting an exception to the certification requirements at

5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

2. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

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