Medical Source Statement of Ability To Do Work-Related Activities (Physical & Mental)

ICR 200210-0960-009

OMB: 0960-0662

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0960-0662 200210-0960-009
Historical Active
SSA
Medical Source Statement of Ability To Do Work-Related Activities (Physical & Mental)
Existing collection in use without an OMB Control Number   No
Regular
Approved with change 12/24/2002
Retrieve Notice of Action (NOA) 10/21/2002
Approved for use through 12/2005 under the condition that SSA amends the PRA disclosure statement to include a solicitation for public comment.
  Inventory as of this Action Requested Previously Approved
12/31/2005 12/31/2005
20 0 0
50,000 0 0
0 0 0

SSA's Office of Hearings and Appeals (OHA) uses the HA-1151 (Physical) and its companion for HA-1152 (Mental) to collect information that Administrative Law Judges and the Appeals Council of OHA require to determine the residual functional capacity of individuals who are appealing denied claims for benefits based on disability. The respondents are medical sources that provide medical reports.

None
None


No

1
IC Title Form No. Form Name
Medical Source Statement of Ability To Do Work-Related Activities (Physical & Mental) HA-1151, HA-1152

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 20 0 0 20 0 0
Annual Time Burden (Hours) 50,000 0 0 50,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
10/21/2002


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