Addendum to Supporting Statement 0960-0500

Addendum To Supporting Statement for Forms SSA-4814-F5 and SSA-4815-F6

Medical Report on Adult with Allegation of Human

Immunodeficiency Virus Infection;

Medical Report on Child with Allegation of Human

Immunodeficiency Virus Infection

20 CFR, Subpart 416.933-.934

(OMB No. 0960-0500)

Revisions to the Collection Instrucments

We are proposing the following editorial changes to the SSA-4814-F5 and the SSA-4815-F6 as a result of the editorial changes that we made to the HIV infection listings as a part of the revised immune system disorders final rule that became effective on June 16, 2008.

Changes to SSA-4814-F5

• Page 1 –– C. OPPORTUNISTIC AND INDICATOR DISEASES

  • C. 8.

    • Change CANDIDIASIS, at a site other than the skin, urinary tract, intestinal tract, or oral or vulvovaginal mucous membranes; or candidiasis involving the esophagus, trachea, bronchi, or lungs to:

      • CANDIDIASIS involving the esophagus, trachea, bronchi, or lungs, or at a site other than the skin, urinary tract, intestinal tract, or oral or vulvovaginal mucous membranes

• Move C. 14. after C. 12. and renumber it as C. 13. and revise as follows:

  • Remove “CARINNI”

• C. 13. revision will read:

  • PNEUMOCYSTIS PNEUMONIA OR EXTRAPULMONARY PNEUMOCYSTIS INFECTION

• Renumber current C. 13. to C. 14.

• C. 14. will read (same as current C. 13):

  • CRYPTOSPORIDIOSIS, ISOSPORIASIS, OR MICROSPORIDIOSIS, with diarrhea lasting for 1 month or longer

• Page 2 — C. OPPORTUNISTIC AND INDICATOR DISEASES

  • C. 25.

    • Replace “anus”

      • with “anal canal or anal margin”

• C. 25. revision will read:

  • SQUAMOUS CELL CARCINOMA OF THE ANAL CANAL OR ANAL MARGIN

• Page 3 — D. OTHER MANIFESTATIONS OF HIV INFECTION

• D. 42. a.

  • In the parenthetical phrase that begins with e.g., insert “severe” before “fatigue” and “involuntary” before “weight loss”; and after “night sweats” insert “nausea, vomiting, headaches, or insomnia”

• D. 42. a. revision will read:

  • REPEATED MANIFESTATIONS OF HIV INFECTION, including diseases mentioned in section C, items 1-41, but without the specified findings described above, or other diseases, resulting in significant, documented, symptoms or signs (e.g., severe fatigue, fever, malaise, involuntary weight loss, pain, night sweats, nausea, vomiting, headaches, or insomnia).

• D. 42. b.

  • Replace “restriction” with “limitation” in “Marked restriction of ACTIVITIES OF DAILY LIVING”

  • Replace “difficulties” with “limitation” in “Marked difficulties in maintaining SOCIAL FUNCTIONING”

  • Replace “difficulties” with “limitation” in “Marked difficulties in completing tasks in a timely manner due to deficiencies in CONCENTRATION, PERSISTENCE, OR PACE”

• D. 42. b. revision will read:

  • Marked limitation of ACTIVITIES OF DAILY LIVING; or

  • Marked limitation in maintaining SOCIAL FUNCTIONING; or

  • Marked limitation in completing tasks in a timely manner due to deficiencies in CONCENTRATION, PERSISTANCE, OR PACE.

• Page 4 — MEDICAL SOURCE INSTRUCTION SHEET FOR COMPLETION OF ATTACHED SSA-4814-F5

• VI. SPECIAL TERMS USED IN SECTION D—

WHAT WE MEAN BY “MANIFESTATIONS OF HIV INFECTION”: (See Item 42.a)

• In the first bullet:

In the second parenthetical phrase that begins with e.g., insert “pancreatitis, hepatitis, peripheral neuropathy, glucose intolerance, muscle weakness, cognitive or other mental limitation” after “myositis”

• The revised first bullet will read:

“Manifestations of HIV infection” may include:

Any condition listed in section C, but without the findings specified there (e.g., carcinoma of the cervix not meeting the criteria shown in item 22 of the form, diarrhea not meeting the criteria shown in item 33 of the form); or any other condition that is not listed in section C (e.g., oral hairy leukoplakia, myositis, pancreatitis, hepatitis, peripheral neuropathy, glucose intolerance, muscle weakness, cognitive or other mental limitation).

• In the second bullet:

In the parenthetical phrase that begins with e.g., insert “severe” before “fatigue” and “involuntary” before “weight loss”; and after “night sweats” insert “nausea, vomiting, headaches, or insomnia”

• The revised second bullet will read:

Manifestations of HIV must result in significant, documented, symptoms and signs (e.g., severe fatigue, fever, malaise, involuntary weight loss, pain, night sweats, nausea, vomiting, headaches, or insomnia).

• Page 5

WHAT WE MEAN BY “MARKED” LIMITATION OR RESTICTION IN FUNCTIONING: (See Item 42.b)

• Remove “OR RESTRICTION” from the heading.

• The revised heading will read:

  • WHAT WE MEAN BY “MARKED” LIMITATION IN FUNCTIONING: (See Item 42.b)

• In the subheading, WHAT WE MEAN BY “SOCIAL FUNCTIONING”: (See Item 42.b)

• In the second bullet entitled “EXAMPLE” replace “difficulty” with “limitation in”

• The revised second bullet will read:

  • EXAMPLE: An individual with HIV infection who, because of symptoms or a pattern of exacerbation and remission caused by the illness or its treatment, cannot engage in social interaction on a sustained basis (even though he or she is able to communicate with close friends or relatives) would have marked limitation in maintaining social functioning.

• In the subheading, WHAT WE MEAN BY “COMPLETING TASKS IN A TIMELY MANNER”: (See Item 42.b)

• In the second bullet entitled “EXAMPLE” replace “difficulty” with “limitation in”

• The revised second bullet will read:

EXAMPLE: An individual with HIV infection who, because of HIV-related fatigue or other symptoms, is unable to sustain concentration or pace adequate to complete simple work-related tasks (even though he or she is able to do routine activities of daily living) would have marked limitation in completing tasks.

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Changes to SSA-4815-F6

• Page 1 –– C. OPPORTUNISTIC AND INDICATOR DISEASES

• C. 9.

• Change CANDIDIASIS, at a site other than the skin, urinary tract, intestinal tract, or oral or vulvovaginal mucous membranes; or candidiasis involving the esophagus, trachea, bronchi, or lungs

• To: CANDIDIASIS involving the esophagus, trachea, bronchi, or lungs, or at a site other than the skin, urinary tract intestinal tract, or oral or vulvovaginal mucous membranes

• Move C. 15. after C. 13. and renumber it as C. 14. and revise as follows:

• Remove “CARINNI”

• C. 14. revision will read:

  • PNEUMOCYSTIS PNEUMONIA OR EXTRAPULMONARY PNEUMOCYSTIS INFECTION

• Renumber current C. 14. to C. 15.

• C. 15. will read (same as current C. 14):

  • CRYPTOSPORIDIOSIS, ISOSPORIASIS, OR MICROSPORIDIOSIS, with diarrhea lasting for 1 month or longer

• Page 2 — C. OPPORTUNISTIC AND INDICATOR DISEASES

• C. 26.

  • Replace “anus” with “anal canal or anal margin”

• C. 26. revision will read:

  • SQUAMOUS CELL CARCINOMA OF THE ANAL CANAL OR ANAL MARGIN

• C. 31.

  • Replace “acquisition” with “onset”

• Change LOSS OF PREVIOULY ACQUIRED, OR MARKED DELAY IN ACHIEVING, DEVELOPMENTAL MILESTONES OR INTELLECTUAL ABILITY (including the sudden acquisition of a new learning disability)

• To: LOSS OF PREVIOULY ACQUIRED, OR MARKED DELAY IN ACHIEVING, DEVELOPMENTAL MILESTONES OR INTELLECTUAL ABILITY (including the sudden onset of a new learning disability)

Minor Revisions to the Collection Instruments

SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the last page of the forms. SSA is also revising the Paperwork Reduction Act Statement to reflect updated contact information.

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