Request for Hearing By Administrative Law Judge

Forms and Documents

Document Name	Status
Form HA-501 Request for Hearing By Administrative Law Judge--Paper/MCS Version Form	Modified
Form i501 (Internet Ver Request for Hearing By Administrative Law Judge--Internet Version (i501) Form and Instruction	Modified
Supporting Statement 0960- 0269 (revised).docx Supporting Statement A	2011-05-31
Addendum 0960-0269 (revised).docx Supplementary Document	2011-05-31

IC Document Collections

IC ID	Document Title	Status
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	Modified

ICR Details

OMB Control No: 0960-0269	ICR Reference No: 201102-0960-007
Status: Historical Active	Previous ICR Reference No: 201002-0960-021
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: 09/30/2011
	Date Received in OIRA: 06/02/2011
Terms of Clearance: OMB is approving this collection for one year with the following terms of clearance. Upon next submission, SSA should provide a written explanation of the reasons for the wide discrepancy between the average burden associated with the electronic form and the paper version. The explanation should include steps that SSA is taking to reduce this discrepancy. SSA should also provide OMB with up-to-date data on the percentage of Medicare Part B affected beneficiaries who request an appeals hearing.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	36 Months From Approved	09/30/2011
Responses	669,469	0	669,469
Time Burden (Hours)	206,978	0	161,788
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the information collected on Form HA-501-U5 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 respondents are individuals filing for an ALJ hearing.

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Authorizing Statute(s): 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: Social Security Act
   US Code: 42 USC 1320c-4 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 42 USC 1395ff Name of Law: Social Security Act
   US Code: 42 USC 1395r Name of Law: Social Security Act
   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
  

Citations for New Statutory Requirements: None

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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:
	76 FR 11835	03/03/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 30749	05/26/2011
Did the Agency receive public comments on this ICR? No

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

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

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ICR Summary 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)	206,978	161,788	0	0	45,190	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: There has been an increase in burden hours, due to more respondents completing the form online.

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Annual Cost to Federal Government: $55,000

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 06/02/2011

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