Information Collection

Medical Source Statement of Ability to Do Work-Related Activities (Mental)

IC 188400 under ICR 201406-0960-011 · OMB 0960-0662.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0662 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-1152 Medical Source Statement of Ability to Do Work-Related Activities (Mental)	Form
HA-1152 Medical Source Statement of Ability to Do Work-Related A HA-1152-BK.pdf	Form
HA-1152-BK.pdf Current HA-1152	IC Document

IC Title:

Medical Source Statement of Ability to Do Work-Related Activities (Mental)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.917 20 CFR 404.1513 20 CFR 404.1512 20 CFR 416.912 20 CFR 404.1517 20 CFR 416.913

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-1152	Medical Source Statement of Ability to Do Work-Related Activity (Mental)	HA-1152-BK.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	150,000	30,000	120,000
Annual IC Time Burden (Hours)	37,500	7,500	30,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current HA-1152	HA-1152-BK.pdf	09/19/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.