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
Introduction/Authoring Laws and Regulations
As per 20 CFR 404.1513(b)(6) and 416.913(b)(6) of the Code of Federal Regulations (CFR), the Social Security Administration (SSA) may ask 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. Per 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 medical providers who perform these consultative examinations will provide a statement about the claimant’s state of disability. The authority to collect this information is contained in Section 702(a)(5) of the Social Security Act (Act) under Title II and the Supplemental Security Income Program under Title XVI.
Description of Collection
In some instances when a claimant appeals a denied disability claim, SSA may ask the 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. The medical providers who perform these consultative examinations provide a statement about the claimant’s state of disability. Specifically, these medical source statements determine the work-related capabilities of these claimants. SSA collects the medical data on the HA-1151 and HA-1152 to assess the work-related physical and mental capabilities of claimants who appeal SSA’s previous determination on their issue of disability. The respondents are medical sources who provide reports based either on existing medical evidence or on consultative examinations.
Use of Information Technology to Collect the Information
SSA did not create an electronic version of Forms HA-1151 and HA-1152, under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 10,000 respondents complete the forms. This is less than the GPEA cut-off of 50,000
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.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Forms HA-1151 and HA-1152, individuals who may be eligible for benefits might not receive them. Because SSA collects this information on an as needed basis, we cannot collect it less frequently.
There are no technical or legal obstacles that prevent burden reduction.
Special Circumstances
There are no special circumstances that would cause SSA to collect this information in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on July 03, 2014, at
79 FR 38107, and we received no public comments. The 30-day FRN published on September 19, 2014 at 79 FR 56428. If we receive any comments in response to this Notice, we will forward them to OMB.
Payment or Gifts to Respondents
SSA compensates medical sources who provide medical reports and conducts consultative examinations.
Assurances of Confidentiality
SSA protects and holds confidential the information it collects 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.
Justification for Sensitive Questions
The respondents for these forms 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.
Estimates of Public Reporting Burden
Modality of Completion |
Number of Respondents |
Frequency of Response |
Number of Responses |
Average Burden Per Response (minutes) |
Estimated Total Annual Burden (hours) |
HA-1151 |
5,000 |
30 |
150,000 |
15 |
37,500 |
HA-1152 |
5,000 |
30 |
150,000 |
15 |
37,500 |
Totals: |
10,000 |
|
300,000 |
|
75,000 |
The total burden for this ICR is 75,000 hours. This figure represents burden hours, and we did not calculate a separate cost burden
Annual Cost to the Respondents (Other)
There is no known cost burden to respondents beyond that for which SSA compensates them.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $9,000. This estimate is a projection of costs for printing and distributing the collection.
Program Changes or Adjustments to the Information Collection Request
There has been an increase in burden hours. The change stems from an increase in the number of cases being processed by the hearing offices yearly, causing an increase in the request for information and an increase in the burden hours.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying 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.
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 information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement for |
| Author | 413980 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |