Supporting Statement for Form HA-4631,
Claimant’s Recent Medical Treatment
(20 CFR 404.1512 and 416.912)
OMB # 0960-0292
A. Justification
1. Sections 205 (a) , 223 (d) , 1614 (a) , and 1631(e) of the Social Security Act (the Act) requires that a claimant filing for Social Security or Supplemental Security Income (SSI) benefits based on disability, must provide medical and other evidence concerning his or her impairment(s) to the Social Security Administration (SSA).
Sections 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations set forth the procedures and policies for implementing the Act.
Form HA-4631 is a questionnaire used by SSA concerning medical treatment in which SSA will ask claimants to complete if a review of the claim file indicates that updating the medical evidence is necessary. Each claimant who requests a hearing before an Administrative Law Judge (ALJ) has a right to such a hearing once the Disability Determination Service (DDS) at the Reconsideration level has denied the claim. SSA will request that the claimant complete and return the HA-4631 if the claimant’s file does not reflect a complete medical history. Because the claimant's situation may change over time as the claimant proceeds through the appeals process, ALJs must obtain the information on Form HA-4631 to update and complete the record and to verify that information previously provided is accurate. It is by this process that ALJs can determine whether the claimant's situation has changed. The ALJ and Hearing Office (HO) staff use the response to make hearing arrangements, including obtaining a consultative examination(s) and the attendance of an expert witness(es), if appropriate. At the hearing, the ALJ offers any completed questionnaires as exhibits and may use them to refresh the claimant's memory and to inquire into the matters at issue. The respondents are Claimants requesting hearings on entitlement to benefits based on disability under titles II and/or XVI of the Social Security Act.
3. The Office of Disability Adjudication and Review will generate paper copies of the Form HA-4631 electronically. Respondents usually submit their responses on the paper copies. A Portable Document Format (PDF) version of Form HA-4631 is located on SSA’s internet website. For claimants who appoint a representative, electronic submission of Form HA-4631 is available to the claimant’s representative through the Electronic Records Express initiative. Appointment of a representative occurs in about 75-80% of claimant cases. Electronic submission of Form HA-4631 is not currently available to claimants who do not appoint a representative. SSA is currently exploring the feasibility of electronic submission of Form HA-4631 for unrepresented claimants.
4. The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to collect similar data.
5. This collection does not have a significant impact on a substantial number of small businesses or other small entities.
6. In order to comply with Federal law, SSA must collect the information on the HA-4631. If the hearing office (HO) staff does not collect the information when necessary, a violation of the statutory requirements to "develop a complete medical history of at least the preceding twelve months for any case in which a determination is made that the individual is not under a disability” may occur. Therefore, we cannot collect the 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 conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
8. The 60-day advance Federal Register Notice published on December 11, 2008, at 73 FR 75488, and SSA received no public comments. The second Notice published on February 17, 2009, at 74 FR 7506. There have been no outside consultations with members of the public. In the 30-day FRN for this information collection, published on February 17, 2009 at 74 FR 7511, SSA erroneously listed this information collection as an extension of an OMB-approved information collection; it is actually a revision.
9. SSA provides no payment or gifts to the respondents.
10. SSA protects and holds confidential the information it is requesting 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 information collection does not contain any questions of a sensitive nature.
12. Approximately 350,000 respondents will use Form HA-4631 annually. The estimated average response time is 10 minutes, for a total of 58,333 burden hours. The total burden represents burden hours, and SSA did not calculate a separate cost burden.
13. There is no known cost burden to the respondents.
14. The annual cost to the Federal Government is approximately $539,000.00. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
15. The total burden increased from 53,333 to 58,333 hours. This increase occurred because the number of respondents increased from 320,000 to 350,000. SSA did not make any regulatory, policy or procedural changes for this collection. Therefore, we are reporting this as an adjustment.
16. SSA will not publish the results of the information collection.
17. OMB exempted SSA from the requirement to print the OMB approval expiration date on its program forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB approval. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). SSA granted this exemption so the agency would not have to discontinue using otherwise useable editions of forms with outdated expiration dates. In addition, SSA avoids Government waste, because we will 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 is not using statistical methods for this collection
| File Type | application/msword |
| Author | 105426 |
| Last Modified By | Davidson, Liz |
| File Modified | 2009-04-29 |
| File Created | 2009-04-29 |