Information Collection

Medical Source Statement of Ability To Do Work-Related Activities: Physical and Mental

IC 9709 under ICR 200608-0960-007 · OMB 0960-0662.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0662 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-1151 Medical Source Statement of Ability To Do Work-Related Activities: Physical and Mental	Form
HA-1151 MEDICAL SOURCE STATEMENT OF ABILITY TO DO WORK-RELATED A HA-1151 1-2006 revision.doc	Form
HA-1151 09-05 EDIT Medical Source Statement of Ability To Do Work-Related A HA-1151 09-05 EDITION.doc	Form

IC Title:

Medical Source Statement of Ability To Do Work-Related Activities: Physical and Mental

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1512

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-1151	MEDICAL SOURCE STATEMENT OF ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)	HA-1151 1-2006 revision.doc		No		Paper Only
Form	HA-1151 09-05 EDITION	Medical Source Statement of Ability To Do Work-Related Activities (Physical)	HA-1151 09-05 EDITION.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	200,000	200,000
Annual IC Time Burden (Hours)	50,000	50,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.