Request for Hearing By Administrative Law Judge, 20 CFR 404.929, 404.933, 416.1429, 404.1433, 405.722, 418.1350

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form HA-501 Request for Hearing By Administrative Law Judge, 20 CFR 404.933, 20 CFR 405.722	Form	Modified	Available
0960-0269 addendum[1].doc	Supplementary Document	Uploaded 2007-02-20	Available
old HA-501.pdf	Supplementary Document	Uploaded 2007-02-20	Available
0960-0269 full revision clearance supporting statement.doc	Supporting Statement A	Uploaded 0000-00-00	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9174	Request for Hearing By Administrative Law Judge, 20 CFR 404.933, 20 CFR 405.722	Form	Modified

ICR Details

OMB Control No: 0960-0269	ICR Reference No: 200702-0960-007
Status: Historical Active	Previous ICR Reference No: 200610-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Hearing By Administrative Law Judge, 20 CFR 404.929, 404.933, 416.1429, 404.1433, 405.722, 418.1350
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/03/2007
	Date Received in OIRA: 02/22/2007
Terms of Clearance: At the expiration of this collection, SSA will update OMB on the progress of electronic conversion and implementation, currently scheduled for September 2007 (4/24/07). SSA will also work on obtaining data on the percentage of Medicare Part B affected beneficiaries who request an appeals hearing for the renewal of this collection (5/1/07).

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2010	36 Months From Approved	05/31/2007
Responses	669,469	0	669,469
Time Burden (Hours)	111,578	0	111,578
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses form HA-501 to document when applicants for Social Security benefits have their claims denied and want to request an administrative hearing to appeal SSA’s decision. The current ICR is for full clearance of the new Medicare Part-B related changes which were recently approved on an emergency basis.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 1350 Name of Law: Medicare Modernization Act of 2003
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 1350 Name of Law: Medicare Modernization Act of 2003

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 75607	12/15/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 7809	02/20/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Request for Hearing By Administrative Law Judge, 20 CFR 404.933, 20 CFR 405.722	HA-501	Request for Hearing By Administrative Law Judge

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ICR Summary of Burden

table that charts list of burden

	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	669,469	669,469	0	0	0	0
Annual Time Burden (Hours)	111,578	111,578	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,050,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 02/22/2007

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