Supporting Statement for Forms SSA-4814-F5 and SSA-4815-F6
Medical Report on Adult with Allegation of
Human Immunodeficiency Virus Infection;
Medical Report on Child with Allegation of
Human Immunodeficiency Virus Infection
20 CFR, Subpart 416.933-416.934
OMB No. 0960-0500
Justification
Section 1631(e)(i), Title XVI, of the Social Security Act (the Act) authorizes the Social Security Administration (SSA) to gather information to make a determination on an applicant's claim for Supplemental Security Income (SSI) payments. Under the provisions of 20 CFR 416.933-416.934, of the Code of Federal Regulations, SSA or State agencies may make findings of presumptive disability (PD) or presumptive blindness if there is evidence to support the probability that the individual is disabled.
2. Collection of the information on Forms SSA-4814-F5 and
SSA-4815-F6 is necessary for SSA to determine if an individual with human immunodeficiency virus (HIV) infection meets the requirements for PD payments. SSA mails the appropriate form to the claimant's medical source for completion and return to SSA. If SSA is unable to make a PD finding based on the information provided, the state agency is free to do so at their discretion. The respondents are the medical sources of the applicants for SSI disability payments.
3. SSA has not currently scheduled Forms SSA-4814-F5 and
SSA-4815-F6 for electronic implementation given the individualized nature of the evidence respondents will be submitting and due to the low volume of usage and the agency’s limited resources.
4. The nature of the information we are collecting and the and the manner in which we are collecting it preclude duplication. We do not have any other collection instruments that collects similar data .
5. This collection does not have an impact on small businesses or other small entities.
If we did not have this information collection, SSA would not be able to make PD payments for individuals with HIV. Therefore, SSA cannot collect this information less frequently. There are no technical or legal obstacles that prevent burden reduction.
7. There are no special circumstances that would cause SSA to collect this information in a manner that is not consistent with 5 CFR 1320.5.
8. SSA published a final rule on the Revised Criteria for Evaluating Immune System Disorders in the Federal Register on March 18, 2008
and became effective on June 16, 2008. Prior to the publication of the final rule, there were outside consultations with members of the public.
SSA hosted policy conferences on “Immune System Disorders in the Disability Programs” in Philadelphia, Pennsylvania on December 15, 2003, and in San Francisco, California, on February 18 and 19, 2004.
At these conferences, SSA heard comments and suggestions for updating and revising these rules from individuals who have immune system disorders and their family members; physicians who treat individuals with immune system disorders; other professionals who work with people who have immune system disorders; advocates who represent individuals with immune system disorders; and, individuals who make disability determinations and decisions for SSA in the State agencies.
SSA published the 60-day advance Federal Register Notice on September 17, 2008 at 73 FR 53919, and we have received no public comments. SSA published the 30-day Federal Register Notice on January 15, 2009, at 74 FR 2643, and SSA had no outside consultations with members of the public.
9. SSA provides no payment or gifts to the respondents.
10. SSA protects and holds confidential the information from this form 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. The respondents for these forms must provide medical information which could be considered sensitive by its nature. However, SSA needs this information in order to permit an early PD determination for those individuals alleging HIV infection.
12. Below is the burden information. The total burden is
reflected as burden hours, and SSA did not calculate a separate cost burden.
Form |
Number of Responses |
Frequency of Response |
Average Burden Per Response (minutes) |
Estimated Annual Burden (hours) |
SSA-4814-F5 |
46,200 |
1 |
10
|
7,700 |
SSA-4815-F6 |
12,900 |
1 |
10 |
2,150 |
Totals |
59,100 |
-- |
-- |
9,850 |
13. There is no known cost burden to the respondents.
14. The annual cost to the Federal government is approximately $273,042. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
15. There are no changes in the public reporting burden. However, prior to ROCIS, SSA was unable to show the separate time estimates for each form. Because ROCIS now allows us to separate the two forms, we are reporting the burdens per form separately; therefore, the burden estimate is more accurate.
16. SSA will not publish the results of the information collection.
17. OMB exempted SSA from publishing the expiration date for OMB approval on its forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB clearance. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). OMB granted this exemption so that SSA would not have to stop using otherwise useable editions of forms with outdated expiration dates. In addition, SSA avoids Government waste because we do not have to destroy and reprint stocks of forms.
18. 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).
B. Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
| File Type | application/msword |
| File Title | November 2002 |
| Author | 673560 |
| Last Modified By | Davidson, Liz |
| File Modified | 2009-01-26 |
| File Created | 2009-01-26 |