Medical Report will Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child

Forms and Documents

Document	Type	Status	Availability
Form SSA-4814-F5 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult	Form and Instruction	Modified	Available
Form SSA-4815-F6 Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Repair queued
0500 addendum.doc	Supplementary Document	Uploaded 2011-10-21	Repair queued
Supporting Statement OMB 0960-0500 (revised).doc	Supporting Statement A	Uploaded 2012-02-27	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
9396	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult	Form and Instruction	Modified
187514	Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0500	ICR Reference No: 201109-0960-009
Status: Historical Active	Previous ICR Reference No: 200809-0960-003
Agency/Subagency: SSA	Agency Tracking No:
Title: Medical Report will Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/27/2012
	Date Received in OIRA: 01/26/2012
Terms of Clearance: This collection is cleared based on the revised materials provided by the Agency.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2015	36 Months From Approved	04/30/2012
Responses	59,100	0	59,100
Time Burden (Hours)	9,850	0	9,850
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA uses Forms SSA-4814-F5 and SSA-4815-F6 to collect information necessary to determine if an individual with HIV, who is applying for SSI disability benefits, meets the requirements for presumptive disability payments. The respondents are the medical sources of the applicants for SSI disability payments.

---

Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
  

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:
	76 FR 65315	10/20/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 2114	01/13/2012
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult	SSA-4814-F5	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection
Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	SSA-4815-F6	Medical Report on Child with Allegation of Human Immunodeficiency virus (HIV) Infection

---

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	59,100	59,100	0	0	0	0
Annual Time Burden (Hours)	9,850	9,850	0	0	0	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:

---

Annual Cost to Federal Government: $273,042

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

---

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: 01/26/2012

---