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, and 416.917
OMB No. 0960-0662
A. Justification
Introduction/Authoring Laws and Regulations
Sections 20 CFR 404.1513(b)(6) and 416.913(b)(6) of the Code of Federal Regulations allow the Social Security Administration (SSA) to ask medical sources to provide a statement about what work-related activities claimants can do despite their impairments. 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 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 under Title II and the Supplemental Security Income Program under Title XVI.
Description of Collection
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 electronic versions 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 collect and the manner in which we collect 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 payments might not receive them. Because we collect this information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.
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.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on May 12, 2017, at 82 FR 22173, and we received no public comments. The 30-day FRN published on August 16, 2017 at 82 FR 38982. 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 conduct consultative examinations when the claimants cannot afford them.
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 payments. 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
The following burden chart shows the estimated annual burden information for each of the modalities we use to collect the information. We based these figures on our current management information data:
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 accounts for costs from the following areas: (1) designing, printing, and distributing the forms; (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time; and (3) costs associated with medical sources to complete medical reports and conduct consultative examinations when claimants cannot afford them.
Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.
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 | 2021-01-22 |