Supporting Statement 0662

3

Supporting Statement for Form HA-1151

Medical Source Statement of Ability

To Do Work-Related Activities (Physical) and

Form HA-1152 Medical Source Statement of Ability

To Do Work-Related Activities (Mental)

20 CFR 404.1512-404.1513, 416.912-416.913, 404.1517, 416.917

OMB No. 0960-0662

A. Justification

1. Under 20 CFR 404.1513(b)(6) and 416.913(b)(6) of the Code of Federal Regulations (CFR), the Social Security Administration (SSA) may request medical sources to provide a statement about what work-related activities a claimant can do despite his or her impairment. Sections 20 CFR 404.1517 and 416.917 provide that SSA may ask a claimant to have a consultative examination, at the agency’s expense, if the claimant's medical sources cannot or will not give the agency sufficient evidence to determine whether the claimant is disabled. Under 20 CFR 404.1512 and 416.912, it is the responsibility of the claimant to submit evidence to the SSA-employed medical provider performing the consultative medical examination.

The SSA-employed medical providers who perform these consultative examinations will provide a statement about the claimant’s state of disability. Specifically, these medical source statements are an assessment of the work-related capabilities of claimants who are appealing SSA’s previous decision regarding the claimant’s state of disability. The authority to collect this information is contained in Section 702(a)(5) of the Social Security Act (the Act) under Title II and the Supplemental Security Income Program under Title XVI.

2. SSA will use the information from these medical source statement forms in assessing the work-related capabilities (physical and mental) of claimants who are appealing SSA’s previous determination on their issue of disability. The respondents are medical sources who provide medical reports based either on existing medical evidence or on consultative examinations.

3. Electronic versions of Forms HA-1151 and HA-1152 are currently not available. This information collection originates from SSA. SSA mails the forms at its own initiation to medical providers for completion by a physician or mental health professional. No economically feasible alternative is currently available to distribute the forms electronically to the medical providers. SSA cannot e-mail the forms to the recipients/respondents because they contain personally identifiable information, including the claimant’s name and social security number.

4. The nature of the information SSA is collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument that provides the information collected on the Forms HA-1151 and HA-1152.

5. This collection has no impact on small businesses or other small entities.

6. SSA requests medical sources to complete these forms when the information will assist the agency in redetermining a claimant’s degree of disability in the course of their appeal for benefits. If we did not collect this information, individuals who may be eligible for benefits might not receive them. Because SSA collects this information on a case-by-case basis, we cannot collect it 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 inconsistent with 5 CFR 1320.5.

8. SSA published the 60-day advance Federal Register Notice on October 27, 2008 at 73 FR 63761, and we received no public comments. SSA published the 30-Day Federal Register Notice on February 17, 2009 at 74 FR 7506. If we receive any public comments in response to the 30-Day Notice, we will forward them to OMB.

There have been no outside consultations with members of the public.

9. SSA compensates medical sources who provide medical reports and conducts consultative examinations.

10. SSA protects and holds confidential the information from this form in accordance with 42 U.S.C. 1306, 20 CFR 401 and 422, 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 sometimes provide sensitive medical information; however, SSA needs this information to determine if the claimant qualifies for benefits. SSA does not share this information with anyone outside of the administrative law judge who makes the eligibility determination in appeal cases.

12. We estimate that SSA’s use of each of these forms will generate 100,000 responses annually, that respondents will average 20 reports annually, that the average burden per response will be 15 minutes, and that the annual total burden on all respondents for each form will be 25,000 hours. We base our estimates on current hearing and appeals workloads and on SSA’s current use of the forms.

Forms	Number of Respondents	Frequency of Response	Average Burden Per Response	Burden Hours
HA-1151	5,000	20	15 minutes	25,000
HA-1152	5,000	20	15 minutes	25,000
Totals:	10,000	20	15 minutes	50,000

13. There is no known cost burden to respondents beyond that for which SSA compensates them.

14. The annual costs specifically associated with the use of these forms include the costs to generate paper copies of the form electronically from personal computers. We estimate that this cost will be about $3,000 for each form per year, for a total of $6000. Any further cost associated with the use of the form relate to the costs of compensating claimants’ medical sources for providing existing medical evidence and costs associated with conducting consultative examinations. SSA has not separated the cost of compensating medical sources for completing statements about a claimant’s ability to do work-related activities.

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, we avoid Government waste because SSA does 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.