Justification for Non-Substantive Change 0960-0500

Justification for Non-Substantive Changes for Forms SSA-4814 and SSA-4815

Medical Report on Adult with Allegation of Human

Immunodeficiency Virus Infection;

Medical Report on Child with Allegation of Human

Immunodeficiency Virus Infection

20 CFR 416.933-416.934

OMB No. 0960-0500

Justification for Non-Substantive Changes to the Collection or Resubmission of the Collection within One Year of OMB Approval

• Change #1: We are updating all the fields where we request date on Form SSA-4814 and SSA-4815. We are adding an arrow on the side where the respondent can pull up a calendar and select the date (the respondent can still type in the date in any format they choose).

Justification #1: We are updating the fields where we request dates to make it easier for the user to enter information. As noted above, users may still enter dates in any format they choose.

• Change #2: We are revising the date format in the example in the table for question 8 on the SSA-4814 and question 7 on the SSA-4815 at the top of page 2 of both forms from “December 2, 2015” to “12/2/2015.”  

Justification #2: We are revising the date format because this date format is consistent with other agency forms and matches the data types SSA stores in our databases.

NOTE: We contemplated changing the date format for this example to MM/YY; however, moving to this format would interfere with the purpose of these forms. SSA uses the SSA-4814 and the SSA-4815 to determine whether a person with an HIV infection appears to meet the listing for HIV (listing 14.11 for adults and listing 114.11 for children), in order to determine whether the person should receive presumptive disability benefits. Listing 14.11H and 114.11G, require a certain number of hospitalizations “within a 12-month period and at least 30 days apart,” the exact date matters, because, in some instances, we would not be able to tell that hospitalizations are at least 30 days apart without it. Therefore, in order to preserve the accuracy of the presumptive disability determinations and the usefulness of these forms, SSA needs to maintain the precise date we use on the current approved forms.