0300 Supporting Statement (revised)

SUPPORTING STATEMENT FOR FORM HA-4633

CLAIMANT'S WORK BACKGROUND

20 CFR 404.1565(b) and 20 CFR 416.965(b)

OMB No. 0960-0300

A. Justification

1. Introduction/Authoring Laws and Regulations

Sections 205(a) and 1631(e) of the Social Security Act (the Act) provide the Commissioner of Social Security with the authority to establish procedures for determining whether a claimant is entitled to disability benefits. The Social Security Administration (SSA) may ask an individual who applies for disability benefits under the Act describes background information about work done in the past 15 years, as described in 20 CFR, 404.1512(a), 404.1565(b),416.912(a) and 416.965(b) of the Code of Federal Regulations. Form HA‑4633 facilitates the collection of a claimant’s work background.

2. Description of Collection

SSA may ask individuals who are requesting a hearing before an administrative law judge (ALJ), due to denial of benefits application, to provide background information about work they performed in the past 15 years. SSA uses the information Form HA-4633 collects to assess an individual’s disability and review an updated summary of the individual’s relevant work history, as required by an ALJ to accurately assess the claimant’s disability. The ALJ makes the completed HA-4633 part of the documentary evidence of record. If SSA finds the claimant to be disabled without consideration of his or her work history, completion of the Form HA-4633 is not necessary. A select population of claimants who are determined solely at the discretion of the ALJ based on the conditions of each individual claimant’s hearing complete the HA-4633. The respondents are claimants for disability benefits under title II or title XVI who requested a hearing before an ALJ after having their application for disability payments denied.

3. Use of Information Technology to Collect the Information

A PDF version of Form HA-4633 is available on SSA’s website, for claimants to download, print, and mail back to SSA.

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an Internet version of Form HA-4633, (for claimant’s representative through the Electronic Records Express initiative). Based on our data, we estimate approximately 80% of respondents under this OMB number use the electronic version.

SSA did not create an electronic version of Form HA-4633, for the respondents who do not appoint a representative under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 25,000 respondents complete the form. This is less than the GPEA cut-off of 50,000.

4. Why We Cannot Use Duplicate Information

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 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 we did not use Form SSA-4633, the claimants might not have the ability to present evidence pertinent to their claim for disability benefits. Because we collect the information on an as needed basis, 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 collect this information 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 July 13, 2011, at 76 FR 41320, and we received no public comments. The 30-day FRN published on October 20, 2011, at 76 FR 65315. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult the public on the maintenance of this form.

9. Payment or Gifts to Respondents

SSA does not provide payment or gifts to the respondents.

10. Assurances of Confidentiality

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. Justification for Sensitive Questions

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

12. Estimates of Public Reporting Burden

Approximately 200,000 respondents take 15 minutes each to complete form

HA-4633 each year. Accordingly, the burden is 50,000. This figure represents burden hours and we did not calculate a separate cost burden.

Collection Instrument	Number or respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
HA-4633	200,000	1	15	50,000

13. Annual Cost to the Respondents (Other)

There is no known cost burden to the respondents.

14. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $1,162,700. This estimate is a projection of printing and distribution expenditures for the form and the cost of collecting the information.

15. Program Changes or Adjustments to the Information Collection Request

There has been an increase in burden hours. This change stems from an increase respondents requesting hearing before an ALJ, due to denial of benefits.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collected.

17. Displaying the OMB Approval Expiration Date

For the paper Form SSA-4633, 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.

For the Internet version of Form SSA-4633, SSA is not requesting an exception to the requirement to display the OMB approval expiration date .

18. Exceptions 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).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this collection.