Request for Hearing By Administrative Law Judge

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form HA-501 Request for Hearing By Administrative Law Judge--Paper/MCS Version	Form	Modified	Available
Form i501 (Internet Ver Request for Hearing By Administrative Law Judge--Internet Version (i501)	Form and Instruction	New	Available
iAppeals Flow Chart.pdf	Supplementary Document	Uploaded 2007-06-28	Available
Supporting Statement--0269 (iAppeals).doc	Supporting Statement A	Uploaded 2007-06-29	Available
Addendum--0269.doc	Supplementary Document	Uploaded 2007-06-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9174	Request for Hearing By Administrative Law Judge--Paper/MCS Version	Form	Modified
180726	Request for Hearing By Administrative Law Judge--Internet Version (i501)	Form and Instruction	New

ICR Details

OMB Control No: 0960-0269	ICR Reference No: 200706-0960-003
Status: Historical Active	Previous ICR Reference No: 200702-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Hearing By Administrative Law Judge
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: 08/22/2007
	Date Received in OIRA: 06/29/2007
Terms of Clearance: To further minimize burden on the public, upon next submission, SSA should report on the different ways they have considered to narrow the discrepancy between the average burden associated with the electronic form (22 minutes) and the paper version (10 minutes) between now and next submission. SSA will also continue to obtain updated data on the percentage of Medicare Part B affected benes who request an appeals hearing and report this data on next submission.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2010	36 Months From Approved	05/31/2010
Responses	669,469	0	669,469
Time Burden (Hours)	178,525	0	111,578
Cost Burden (Dollars)	0	0	0

---

Abstract: The information collected on Form HA-501-U5 is used by SSA to document and initiate the Administrative Law Judge (ALJ) hearing process for determining eligibility or entitlement to Social Security benefits (Title II), Supplemental Security Income payments (Title XVI), Special Veterans Benefits (Title VIII), Medicare (Title XVIII), and of initial determinations regarding Medicare Part B income-related premium subsidy reductions. The methods for filing a request for an ALJ hearing are being expanded to include the internet. If an individual receives a notice of denial of his/her disability claim and the notice provides rights to an ALJ hearing, he/she will have the option of filing for the ALJ hearing over the internet. The individual will complete the appropriate appeal screens and submit the appeal to SSA for processing. The respondents are individuals filing for an ALJ hearing.

---

Authorizing Statute(s): PL: Pub.L. 108 - 173 1350 & 931 Name of Law: Medicare Modernization Act of 2003
   PL: Pub.L. 106 - 169 251 & 809 Name of Law: Foster Care Independence Act of 1999
   PL: Pub.L. 103 - 296 105(a)(2)(B) Name of Law: Social Security Independence and Program Improvements Act
   US Code: 42 USC 405 Name of Law: null
   US Code: 42 USC 1320c-4 Name of Law: null
   US Code: 42 USC 1383 Name of Law: null
   US Code: 42 USC 1395ff Name of Law: null
   US Code: 42 USC 1395r Name of Law: null
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 17980	04/10/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 35293	06/27/2007
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Request for Hearing By Administrative Law Judge--Paper/MCS Version	HA-501 (MSSICS Screens), HA-501, HA-501 (MCS Screens)	Request for Hearing By Administrative Law Judge ,   Request for Hearing By Administrative Law Judge ,   Request for Hearing By Administrative Law Judge
Request for Hearing By Administrative Law Judge--Internet Version (i501)	i501 (Internet Version of HA-501)	Request for Hearing By Administrative Law Judge

---

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)	178,525	111,578	0	66,947	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Using Information Technology

Short Statement: The increase in the public reporting burden is due to the estimated increase in completion time for the new i501 (Internet version) as a part of the new iAppeals Program. The decrease in the public reporting burden for the paper HA-501 is due to SSA's anticipation that half of our current respondents will switch to the new iAppeals Internet version (i501) after implementation of the new program.

---

Annual Cost to Federal Government: $2,653,906

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

---

Common Form ICR:  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:

(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: 06/29/2007

---