SUPPORTING STATEMENT FOR FORM HA-4632
CLAIMANT'S MEDICATIONS
20 CFR, 404.1512 and 416.912
OMB No. 0960-0289
A. Justification
1. Sections 205(a), 223(d), 1614(a), and 1631(e) of the Social Security Act (the Act), as amended, and 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations authorize the Social Security Administration (SSA) to collect the information on Form HA-4632. The Act and the regulations require that a claimant filing for Social Security, Old Age, Survivors and Disability Insurance (OASDI) or Supplemental Security Income (SSI) payments based on disability must provide SSA with evidence that shows how the claimant's impairment(s) affects his or her ability to work. The information requested on the form facilitates collecting medical information to support the claimant's application.
2. Form HA-4632 is a questionnaire concerning the claimant's medications. In cases where a claimant is requesting a hearing after denial of his or her disability claim for Social Security benefits, SSA uses Form HA-4632 to request information from the claimant regarding the medications he or she is using. This information helps the Administrative Law Judge (ALJ) hearing the case to inquire fully into the medical treatment the claimant is receiving and the effect of medications on the claimant’s medical impairments and functional capacity. The ALJ makes the completed form a part of the documentary evidence of record, i.e., places it in the official record of the proceedings as an exhibit. Respondents are applicants for OASDI benefits and SSI payments or their representatives.
3. Form HA-4632 is currently available in a portable document format (PDF) on the SSA website where claimants can print, fill out, and send or take the completed form to SSA for processing. For claimants who appoint a representative, electronic submission of Form HA-4632 is now available to the claimant’s representative through the Electronic Records Express initiative. Appointment of a representative occurs in about 80 percent of claimant cases.
4. The nature of the information SSA is collecting and the manner in which we are collecting it preclude duplication. There is no other collection instrument used by SSA that collects data similar to that collected here.
5. This collection does not affect small businesses or other small entities.
6. If SSA did not collect this information, the agency may deprive claimants of their right to present evidence pertaining to their benefit claims, thus causing the agency to violate statutory and regulatory requirements relating to fair hearings and due process. Therefore, SSA cannot collect the information less frequently. There are no technical or legal obstacles that prevent burden reduction.
There are no special circumstances that would cause SSA to collect this information in a manner inconsistent with 5 CFR 1320.5.
SSA published the 60-day advance Federal Register Notice on February 17, 2009 at 74 FR 7506, and we received no public comments. We published the 30-day Federal Register Notice on April 24, 2009 at 74 FR 18782. There have been no outside consultations with members of the public.
9. SSA provides no payment or gifts to the respondents.
10. The information requested is protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.
11. The information collection does not contain any questions of a sensitive nature.
12. Approximately 200,000 respondents will use Form HA-4632 annually. The estimated average response time is 15 minutes, for a total of 50,000 burden hours. The total burden reflects burden hours, and we have not calculated a separate cost burden.
Collection Method |
Number of Respondents |
Estimated Completion Time |
Burden Hours |
PDF/paper form |
20,000 |
15 minutes |
5,000 |
Electronic Records Express |
180,000 |
15 minutes |
45,000 |
Total |
200,000 |
|
50,000 |
13. There is no known cost burden to the respondents.
14. The annual cost to the Federal Government is approximately $308,000. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
15. The increase in the burden hours relates proportionately to the increased number of claims filed over the last 3 years. Further, prior to ROCIS we could not show the separation of collection methods in the burden.
16. SSA will not publish the results of the information collection.
OMB exempted SSA from publishing the expiration date for OMB approval on its forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB clearance. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). OMB granted this exemption so that SSA would not have to stop using otherwise useable editions of forms with outdated expiration dates. In addition, we avoid government waste because we do not have to destroy and reprint stocks of forms.
18. SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).
B. Collections of Information Employing Statistical Methods
SSA did not use statistical methods for this information collection.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR FORM HA-4632, |
| Author | 326628 |
| Last Modified By | Debbie |
| File Modified | 2009-06-10 |
| File Created | 2009-05-11 |