Supporting Statement 0960-0292(revised)

Supporting Statement for Form HA-4631

Claimant's Recent Medical Treatment

20 CFR 404.1512 and 416.912

OMB No. 0960-0292

A. Justification

1. Introduction /Authoring Laws and Regulations

Sections 205 (a) , 223 (d) , 1614 (a) , and 1631(e) of the Social Security Act (Act) require claimants filing for Social Security benefits or Supplemental Security Income (SSI) payments based on disability to provide medical and other evidence concerning their 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.

2. Description of Collection

When Disability Determination Services deny a claim at the reconsideration level, the claimant has a right to request a hearing before an administrative law judge (ALJ). For the hearing, SSA asks the claimant to complete and return the HA-4631 if the claimant’s file does not reflect a current, complete medical history as the claimant proceeds through the appeals process. ALJs must obtain the information to update and complete the claimant’s record, and to verify the accuracy of the information. Through this process, ALJs can ascertain whether the claimant's situation has changed. The ALJs and hearing office staff use the response to make arrangements for consultative examination(s) and the attendance of an expert witness(es), if appropriate. During the hearing, the ALJ offers any completed questionnaires as exhibits, and may use them to refresh the claimant’s memory and to help shape their questions. The respondents are claimants requesting hearings on entitlement to Old Age, Survivors, and Disability Insurance benefits or SSI payments.

2. Use of Information Technology to Collect the Information

Only a select population of claimants, determined solely at the discretion of the ALJ based on the conditions of each individual claimant’s hearing, completes the HA-4631. A PDF version of the HA-4631 form is available for download and printing by the claimants on the internet.

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 80% of claimant cases. Electronic submission of Form HA-4631 is not available to claimants who do not appoint a representative. Given the individualized nature of the evidence respondents will be submitting and the intermittent request for this information, SSA did not deem it appropriate to develop an electronic form under the aegis of the Government Paperwork Elimination Act plan.

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 collect similar data.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequences of Not Collecting Information or Collecting it Less Frequently

If we did not use Form HA-631, ALJs would not have current and complete medical history to determine whether the claimant’s situation has changed; which could result in denial off the claimant’s claim. 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 conduct this information collection 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 September 25, 2014, at

79 FR 57650 and we received no public comments. The 30-day FRN published on December 5, 2014 at 79 FR 72237. If we receive any comments in response to this Notice, we will forward them to OMB.

9. Payments of Gifts to Respondents

SSA does not provide payment or gifts to the respondents.

10. Assurances of Confidentiality

SSA protects and holds confidential the information we are 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. Justification for Sensitive Questions

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

12. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
HA-4631	200,000	1	10	33,333

The total burden for this ICR is 33,333 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Cost to Respondents

There is no known cost burden to the respondents.

14. Annual Cost to the Federal Government

The annual cost to the Federal Government is approximately $539,000. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. Program Changes or Adjustments to the Information Collection

There are no changes to the public reporting burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB 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.

18. Exception 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 is not using statistical methods for this collection.