Supporting Statement - 0662

Supporting Statement for

Form HA-1151 Medical Statement of Ability

To Do Work-Related Activities (Physical) and

Form HA-1152 Medical 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

1. 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.

2. 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.

3. Use of Information Technology to Collect the Information

We currently collect this information via mail or fax only. To help hearings offices scan the information into the correct electronic folder for the claim, we print these forms with barcode prior to sending them to the respondents. SSA’s hearings system reads the barcode to determine the appropriate claims folder to use when saving the data after the hearings office employee scans the completed form into the system, or the respondent faxes the form directly into SSA’s system. This collection does not currently have a fully public-facing Internet version, as we prioritized other information collections for full electronic conversions.  As per our 4/3/20 conversation with OIRA, we welcome OIRA to join our conversations with OMB on IT Mods; however, as our IT Mod programming is an ongoing project, we cannot provide timelines for when we will be able to make any particular ICR available via the Internet.  We will convert existing ICRs to full electronic versions depending on how they fall within our overall IT Mod schema, but this unconnected to the PRA approval lifecycle.

4. 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.

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 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.

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 November 27, 2020, at 85 FR 76142, and we received no public comments. The 30-day FRN published on January 28, 2021 at 86 FR 7446. If we receive any comments in response to this Notice, we will forward them to OMB.

9. Payment or Gifts to Respondents

SSA compensates medical sources who provide medical reports and conduct consultative examinations when the claimants cannot afford them. Since we account for this compensation under OMB Control No. 0960-0555, we do not account for it here.

10. 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.

11. 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.

12. 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)	Average Theoretical Hourly Cost Amount (dollars)*	Total Annual Opportunity Cost (dollars)**
HA-1151	5,000	30	150,000	15	37,500	$39.40*	$1,477,500**
HA-1152	5,000	30	150,000	15	37,500	$39.40*	$1,477,500**
Totals	10,000		300,000		75,000		$2,955,000**

* We based this figure on average medical professionals’ salaries, as reported by the U.S. Bureau of Labor Statistics (https://www.bls.gov/oes/current/oes290000.htm).

** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

We base our burden estimates on current management information data, which includes data from years of conducting this information collection. Per our management information data, we believe that 15 minutes accurately shows the average burden per response for reading the instructions, gathering the facts, and answering the questions. The total burden for this ICR is 75,000 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $2,955,000. SSA does not charge respondents to complete our applications.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents beyond that for which SSA compensates them.

14. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $336,387. This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars*
Designing and Printing the Form	Design Cost + Printing Cost	$31,417
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$174,000
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$127,550
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0
Systems Development, Updating, and Maintenance	GS-9 employee x man hours for development, updating, maintenance	$3,420
Quantifiable IT Costs	Any additional IT costs	$0
Total		$336,387

* This is an average cost of all the forms for VRM and this cost may increase or decrease for this form upon implementation.

SSA is unable to break down the costs to the Federal government further than we already have.  Currently, SSA does not print or store these forms.  The Office of Hearings Operations (OHO) prints the form(s) locally and mails it to the claimant’s medical source(s) who completes and returns it to OHO by mail (the costs for printing and mailing are included in the first two lines of the above chart).  An OHO employee scans the form into the electronic record file, or the respondent faxes the form directly to the scanner with the barcodes, and the system scans the form into the electronic record file.  There is almost no time involved so the cost is minimal.  It is not mandatory to send these forms to medical sources.  We have calculated these costs as accurately as possible based on the information we collect for creating, updating, processing, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection Request

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 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.

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 information collection.