Justification for the Non-Substantive Changes for 0960-0710 (IT Mod Change Request)

Justification for Non-Substantive Changes to

Form HA-85: Request to Withdraw a Hearing Request

20 CFR 404.971 and 416.972

OMB No. 0960-0710

Background

If a claimant wishes to withdraw a request for hearing before the hearing is held or before a judge mails the hearing decision, the judge may dismiss the hearing. The claimant can make the request to withdraw the hearing in writing, or orally at the hearing, or in a hearing office. The agency created Form HA-85 for claimants and representatives to use as written notice of the withdrawal of a hearing request. While use of Form HA-85 is voluntary (as the claimant or representative may request the dismissal orally or in writing separately from the use of the form), the form captures the key information required to process the request.

While we still accept, and will continue to accept, paper versions of the HA-85 and other written or oral requests for a withdrawal of a hearing, we created an online fillable and submittable version of the HA-85, which utilizes Adobe Sign technology to accept and process an electronic signature (eSignature). The online version of the HA-85 mirrors the paper version and provides respondents with an online service option as an alternative to mailing or faxing the form (or their written request) to the servicing hearing office. Claimants and appointed representatives will be able to initiate the online version from our website and complete, electronically sign, and submit it online using the Adobe Sign web application. Use of the Adobe Sign web application does not present any added burden on respondents. Respondents will not be required to download and install the application locally on their device, nor will they have to pay any subscription or licensing fees.

With this new modality for submission, respondents will enter their responses into structured data fields on the online HA-85 screens within the Adobe platform by following a secure link that Adobe Sign sends to the email address the respondent (i.e., claimant or appointed representative) provides. The respondent receives an email from Adobe Sign with instructions for how to access, complete, eSign, and submit the form using this online service. Upon submission, the online HA-85 electronically transmits an image of the completed form to the Electronic Viewing System (eVIEW) for processing by the servicing hearing office.

To protect the respondent’s privacy, the respondent will create a password to protect access to the form. To view the completed form, the respondent will need to enter the password correctly before obtaining access to the information. The Adobe Sign platform will provide a copy of the completed form to the respondent via a password-protected link in an email. Finally, each session will time‑out after 60 minutes of inactivity. The respondent will need to use the link to re-enter the form, enter their password, and then continue completing the submittable version. The submittable HA-85 will be available to the respondent for five (5) days, during which Adobe Sign will send daily email reminders to ensure timely submission and prevent unnecessary delays in processing the withdrawal request. After those five (5) days, the link will expire, and the respondent will need to restart the process by requesting a new link and starting a new form.

Once received, the hearing office will process the request for withdrawal of a hearing using current business processes and policies.

We are submitting this IT Modification as a non-substantive change request to create a submittable PDF for Form HA-85, Request to Withdraw a Hearing Request which mirrors the current paper form. We intend to implement this submittable PDF on July 31, 2021.

Revisions to the Collection Instrument for the Online Modality

• Change #1: On the first screen for the online HA-85, the respondent must read and acknowledge instructions and the Privacy Act Statement associated with the HA-85.

Justification: The instructions provide key information to the respondent about the Adobe Sign process, as described in the above background information.

• Change #2: The second screen requires the respondent to enter and confirm their email address and to establish and confirm a password.

Justification: Once the respondent submits the email address and creates a password, they will receive an email from Adobe Sign with a secure link to complete the form electronically.

SSA will implement the online HA-85 upon OMB’s approval. Since we are not requiring any additional information, and we are making no substantive changes to the content of the HA-85 other than to adapt it to the new electronic submission method and make minor revisions to the instructions, we expect no change in the current burden information for this collection.

As stated above, we intend to implement the submittable PDF modality on July 31, 2021. Therefore, we are asking OMB to approve this IT Modification request as soon as possible so we can meet our implementation date.

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