Medical Source Statement of Ability to Do Work-Related Activities

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form HA-1151 Medical Source Statement of Ability To Do Work-Related Activities (Physical)	Form	Modified	Repair queued
Form HA-1152 Medical Source Statement of Ability to Do Work-Related Activities (Mental)	Form	Modified	Repair queued
Addendum 0662.doc	Supplementary Document	Uploaded 2014-06-23	Available
Supporting Statement 0960-0662(revised).docx	Supporting Statement A	Uploaded 2014-09-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9709	Medical Source Statement of Ability To Do Work-Related Activities (Physical)	Form	Modified
188400	Medical Source Statement of Ability to Do Work-Related Activities (Mental)	Form	Modified

ICR Details

OMB Control No: 0960-0662	ICR Reference No: 201406-0960-011
Status: Historical Active	Previous ICR Reference No: 201109-0960-011
Agency/Subagency: SSA	Agency Tracking No:
Title: Medical Source Statement of Ability to Do Work-Related Activities
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: 10/24/2014
	Date Received in OIRA: 09/24/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2017	36 Months From Approved	02/28/2015
Responses	300,000	0	240,000
Time Burden (Hours)	75,000	0	60,000
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA uses Forms HA-1151 and HA-1152 to collect data that is required to determine the residual functional capacity (RFC) of individuals who are appealing denied claims for benefits based on disability. The RFC of an individual must be determined in cases where SSA cannot make a determination on a claim for benefits based on current work activity or on medical facts alone. The respondents are medical sources paid by SSA to provide reports based either on existing medical evidence or on consultative examinations conducted for the purposes of the report.

---

Authorizing Statute(s): US Code: 42 USC 902 Name of Law: Social Security Act
   US Code: 42 USC 1381 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:
	79 FR 38107	07/03/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 56428	09/19/2014
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Medical Source Statement of Ability To Do Work-Related Activities (Physical)	HA-1151	Medical Source Statement of Ability to Do Work-Related Activities (Physical)
Medical Source Statement of Ability to Do Work-Related Activities (Mental)	HA-1152	Medical Source Statement of Ability to Do Work-Related Activity (Mental)

---

ICR Summary of Burden

table that charts list 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	300,000	240,000	0	0	60,000	0
Annual Time Burden (Hours)	75,000	60,000	0	0	15,000	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. The change stems from an increase in the number of cases being processed by the hearing offices yearly, causing an increase in the request for information and an increase in the burden hours.

---

Annual Cost to Federal Government: $9,000

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

---

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: 09/24/2014

---