Supporting Statement for Form HA-1151
Medical Source Statement of Ability
To Do Work-Related Activities (Physical) and
Form HA-1152 Medical Source Statement of Ability
To Do Work-Related Activities (Mental)
20 CFR 404.1512-404.1513, 416.912-416.913, 404.1517, 416.917
OMB No. 0960-0662
A. Justification
Introduction/Authoring Laws and Regulations
As per 20 CFR 404.1513(b)(6) and 416.913(b)(6) of the Code of Federal Regulations (CFR), the Social Security Administration (SSA) may ask medical sources to provide a statement about what work-related activities a claimant can do despite his or her impairment. Sections 20 CFR 404.1517 and 416.917 provide that SSA may ask a claimant to have a consultative examination, at the agency’s expense, if the claimant's medical sources cannot or will not give the agency sufficient evidence to determine whether the claimant is disabled. Per 20 CFR 404.1512 and 416.912, it is the responsibility of the claimant to submit evidence to the SSA-employed medical provider performing the consultative medical examination. The medical providers who perform these consultative examinations will provide a statement about the claimant’s state of disability. The authority to collect this information is contained in section 702(a)(5) of the Social Security Act under title II and the Supplemental Security Income Program under title XVI.
Description of Collection
In some instances when a claimant appeals a denied disability claim, SSA may ask the claimant to have a consultative examination, at the agency’s expense, if the claimant's medical sources cannot or will not give the agency sufficient evidence to determine whether the claimant is disabled. The medical providers who perform these consultative examinations provide a statement about the claimant’s state of disability. Specifically, these medical source statements determine the work-related capabilities of these claimants. SSA collects the medical data on the HA-1151 and HA-1152 to assess the work-related physical and mental capabilities of claimants who appeal SSA’s previous determination on their issue of disability. The respondents are medical sources who provide reports based either on existing medical evidence or on consultative examinations.
Use of Information Technology to Collect the Information
Electronic versions of Forms HA-1151 and HA-1152 are currently not available. This information collection originates from SSA as a partially pre-filled form. SSA mails the forms at its own initiation to medical providers for completion by a physician or mental health professional. No economically feasible alternative is currently available to distribute the forms electronically to the medical providers. SSA cannot e-mail the forms to the recipients or respondents because they contain personally identifiable information, including the claimant’s name and social security number.
Why We Cannot Use Duplicate Information
The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
SSA asks medical sources to complete these forms when the information will assist the agency in determining a claimant’s degree of disability in the course of their appeal for benefits. If we did not collect this information, individuals who may be eligible for benefits might not receive them. Because SSA collects this information on a case-by-case basis, we cannot collect it less frequently. There are no technical or legal obstacles that prevent burden reduction.
Special Circumstances
There are no special circumstances that would cause SSA to collect this information in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on November 7, 2011, at 76 FR 68805, and SSA received no public comments. The second Notice published on January 3, 2012 at 77 FR 147. If we receive any comments in response to the 30-day Notice, we will forward them to OMB. SSA did not consult members of the public in the development or maintenance of this form.
SSA received one public comment regarding the HA-1152 and none pertaining to the HA-1151. The commenter asked SSA to make some minor language changes to the form, and to include some additional questions. The commenter also asked the agency to require all state Disability Determination Services to use the HA-1152.
In light of some potentially significant changes to the regulations regarding mental impairments (See 75 FR 51336), we will consider potential changes after we receive approval for the final regulatory package.
Payment or Gifts to Respondents
SSA compensates medical sources who provide medical reports and conducts consultative examinations.
Assurances of Confidentiality
SSA protects and holds confidential the information it collects 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.
Justification for Sensitive Questions
The respondents for these forms must sometimes provide sensitive medical information; however, SSA needs this information to determine if the claimant qualifies for benefits. SSA does not share this information with anyone outside of the administrative law judge who makes the eligibility determination in appeal cases.
Estimates of Public Reporting Burden
We estimate that SSA’s use of each of these forms will generate 120,000 responses annually, that respondents will average 24 reports annually, that the average burden per response will be 15 minutes, and that the annual total burden on all respondents for each form will be 30,000 hours. We base our estimates on current hearing and appeals workloads and on SSA’s current use of the forms.
Forms |
Number of Respondents |
Frequency of Response |
Number of Responses |
Average Burden Per Response (minutes) |
Estimated Total Annual Burden (hours) |
HA-1151 |
5,000 |
24 |
(120,000) |
15 |
30,000 |
HA-1152
|
5,000 |
24 |
(120,000) |
15 |
30,000 |
Totals: |
10,000 |
|
240,000 |
|
60,000 |
The total burden for this ICR is 60,000 hours. This figure represents burden hours, and we did not calculate a separate cost burden
Annual Cost to the Respondents (Other)
There is no known cost burden to respondents beyond that for which SSA compensates them.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $7,200. The annual costs specifically associated with the use of these forms include the costs to generate paper copies of the form electronically from personal computers. We estimate that this cost will be about $3,600 for each form per year, for a total of $7,200. Any further cost associated with the use of the form relates to the costs of compensating claimants’ medical sources for providing existing medical evidence and costs associated with conducting consultative examinations. SSA does not separate the cost of compensating medical sources for completing statements about a claimant’s ability to do work-related activities from the total cost associated with this collection.
Program Changes or Adjustments to the Information Collection Request
There are no changes in the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public‑use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
Exceptions to Certification Statement
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 does not use statistical methods for this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement for |
| Author | 413980 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |