Medical Source Statement of Ability To Do Work-Related Activities: Physical and Mental

Medical Source Statement of Ability to Do Work-Related Activities,

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0662 can be found here:

Documents and Forms

Document Name Document Type
Form HA-1151 Medical Source Statement of Ability To Do Work-Related Activities: Physical and Mental Form
HA-1151 MEDICAL SOURCE STATEMENT OF ABILITY TO DO WORK-RELATED A HA-1151 1-2006 revision.doc Form
HA-1151 09-05 EDIT Medical Source Statement of Ability To Do Work-Related A HA-1151 09-05 EDITION.doc Form

Information Collection (IC) Details

IC Title:	Medical Source Statement of Ability To Do Work-Related Activities: Physical and Mental	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1512

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-1151	MEDICAL SOURCE STATEMENT OF ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)	HA-1151 1-2006 revision.doc		No		Paper Only
Form	HA-1151 09-05 EDITION	Medical Source Statement of Ability To Do Work-Related Activities (Physical)	HA-1151 09-05 EDITION.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	200,000	200,000
Annual IC Time Burden (Hours)	50,000	50,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.