Request for Review of Hearing Decision/Order

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form HA-520 Request for Review of Hearing Decision/Order	Form	Modified	Available
SSA's Response to the Public Comment from 12-31-07.doc	Supplementary Document	Uploaded 2008-02-29	Available
SSA Form HA-520--current version.pdf	Supplementary Document	Uploaded 2008-01-16	Available
Addendum--0277.doc	Supplementary Document	Uploaded 2008-02-26	Available
Supporting Statement--0277.doc	Supporting Statement A	Uploaded 2008-02-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9181	Request for Review of Hearing Decision/Order	Form	Modified

ICR Details

OMB Control No: 0960-0277	ICR Reference No: 200801-0960-005
Status: Historical Active	Previous ICR Reference No: 200502-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Review of Hearing Decision/Order
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: 04/15/2008
	Date Received in OIRA: 03/13/2008
Terms of Clearance: This information collection is approved as submitted for 3 years. OMB suggests SSA consider and if appropriate, include in its response to the public comment received that the burden estimates are intended to be averages and that it might take individuals more or less time to complete.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2011	36 Months From Approved	04/30/2008
Responses	100,000	0	107,485
Time Burden (Hours)	16,667	0	17,914
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA, through its agents, the disability determination services (DDSs), uses form SSA-3826-F4 to make accurate determinations in disability claims cases. The information collected on the SSA-3826-F4 is used in determining the claimant’s physical and mental status prior to making a disability determination, and to document the disability claims folder with the medical evidence. Thus, it provides disability adjudicators and reviewers with a narrative record and history of the alleged disability and with the objective medical findings necessary to make a disability determination. SSA uses the medical evidence provided on this form in making a determination of whether an individual’s impairment meets the severity and duration requirements required for disability benefits. The respondents are members of the medical community including individual physicians, hospital doctors, medical records librarians, and other medical sources.

---

Authorizing Statute(s): US Code: 42 USC 405 Name of Law: null
   US Code: 42 USC 1383 Name of Law: null
   PL: Pub.L. 106 - 169 251 Name of Law: null
   PL: Pub.L. 106 - 169 809 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 67776	11/30/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 7782	02/11/2008
Did the Agency receive public comments on this ICR? Yes

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Request for Review of Hearing Decision/Order	HA-520	Request for Review of Hearing Decision/Order

---

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	100,000	107,485	0	0	-7,485	0
Annual Time Burden (Hours)	16,667	17,914	0	0	-1,247	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: The burden hour projection has decreased based on an anticipated decrease in the number of appeals to be filed within the next fiscal year. SSA has based this projection on current information regarding the number of appeals filed in FY 2007.

---

Annual Cost to Federal Government: $770,000

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

---

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: 03/13/2008

---