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-.416.934
A. Justification
Introduction/Authoring Laws and Regulations
Section 1631(e)(i) of the Social Security Act (Act) authorizes the Commissioner of the Social Security Administration (SSA) to gather information to make a determination about an applicant's claim for Supplemental Security Income (SSI) payments; this procedure is the Presumptive Disability (PD). Under the provisions of 20 CFR 416.933-416.934 of the Code of Federal Regulations, SSA or State agencies (DDS) may make findings of PD if the agencies find evidence that supports the probability that we will find the individual disabled.
Description of Collection
SSA uses Forms SSA-4814-F5 and SSA-4815-F6 to collect the information necessary to determine if an individual with human immunodeficiency virus (HIV) infection, who is applying for SSI disability payments, meets the requirements for PD. The respondents are the medical sources of the applicants for SSI disability payments.
SSA mails the appropriate paper form to the claimant's medical source to complete and return to SSA. If SSA is unable to make a PD finding based on the information the applicant’s medical source provides, the State agency is free to do so at its discretion.
Use of Information Technology to Collect the Information
SSA did not create an electronic version of these forms under the agency’s Government Paperwork Elimination Act (GPEA) plan because of the individualized nature of the evidence respondents will be submitting and due to the low volume of usage and the agency’s limited resources.
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.
6. Consequence of Not Collecting Information or Collecting it Less Frequently If we did not use Forms SSA-4814-F5 and SSA-4815-F6, SSA would not be able to make PD payments for individuals with HIV infection. Because we only collect the information once, we cannot collect it less frequently.
There are no technical or legal obstacles to burden reduction.
7. Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection 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 July 03, 2014, at
79 FR 38107, and we received no public comments. The 30-day FRN published on October 31, 2014 at 79 FR 64872. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the maintenance of this form.
Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
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 provide medical information that is sensitive by its nature. However, SSA needs this information in order to permit an early PD determination for those individuals alleging HIV infection. Both forms contain an explanation to the respondents that if they complete the form that their patients may receive early payments. The form will include a signed authorization for release of information by the respondents’ patients.
Estimates of Public Reporting Burden
Modality of Completion |
Number of Respondents |
Frequency of Response |
Response Time (minutes) |
Burden (hours) |
SSA-4814-F5 |
46,200 |
1 |
10 |
7,700 |
SSA-4815-F6 |
12,900 |
1 |
10 |
2,150 |
Totals |
59,100 |
- |
- |
9,850 |
The total burden for this ICR is 9,850 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
13. Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden on the respondents.
Annual Cost To Federal Government
The annual cost to the Federal government is approximately $273,042. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
15. Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.
16. Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
17. 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/msword |
| File Title | Title of Information Collection and Form Number(s) |
| Author | Naomi |
| Last Modified By | 889123 |
| File Modified | 2014-10-31 |
| File Created | 2014-06-18 |