Supporting Statement for Form HA-4632
Claimant’s Medications
20 CFR, 404.1512 and 416.912
OMB No. 0960-0289
A. Justification
Introduction /Authoring Laws and Regulations
Sections 205(a), 223(d), 1614(a), and 1631(e) of the Social Security Act (Act), as amended, and 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations authorize the Social Security Administration (SSA) to collect the information on Form HA-4632. The Act and the regulations require claimants filing for Social Security, Old Age, Survivors and Disability Insurance (OASDI) or Supplemental Security Income (SSI) payments based on disability to provide SSA with evidence showing how the claimants' impairment(s) affect their ability to work. The information we request on the form facilitates collecting medical information to support the claimants' applications.
Description of Collection
Form HA-4632 is a questionnaire concerning the claimant's medications. In cases where claimants request a hearing after denial of their disability claim for Social Security, SSA uses Form HA-4632 to request information from the claimant regarding the medications they use. This information helps the administrative law judge overseeing the case to investigate fully: (1) the claimant’s medical treatment and (2) the effects of the medications on the claimant’s medical impairments and functional capacity. The ALJ makes the completed form a part of the documentary evidence of record, i.e., places it in the official record of the proceedings as an exhibit. The respondents are applicants (or their representatives) for OASDI benefits or SSI payments who request a hearing to contest an agency denial of their claim.
Use of Information Technology to Collect the Information
A select population of claimants completes the HA-4632, determined solely at the discretion of the ALJ based on the conditions of each individual claimant’s hearing. SSA makes the HA-4632 form available for the claimants to download and print through our website: http://www.ssa.gov/online/ha-4632.html.
For claimants who appoint a representative, SSA allows electronic submission of Form HA-4632 to the claimant’s representative through the Electronic Records Express initiative. Appointment of a representative occurs in about 80% of claimant cases. Electronic submission of Form HA‑4632 is not available to claimants who do not appoint a representative. Given the individualized nature of the evidence respondents submit, and the intermittent request for this information, SSA did not deem it appropriate to develop an electronic form under the aegis of the Government Paperwork Elimination Act plan.
Why We Cannot Use Duplicate Information
The nature of the information SSA collects and the manner in which we collect it precludes duplication. SSA uses no other collection instrument to collect similar data.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequences of Not Collecting Information or Collecting it Less Frequently
If SSA did not collect this information, the agency may deprive claimants of their right to present evidence pertaining to their benefit claims, thus causing the agency to violate statutory and regulatory requirements relating to fair hearings and due process. Therefore, SSA cannot collect the information 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
SSA published the 60-day advance Federal Register Notice on March 9, 2015 at 80 FR 12542, and we received no public comments. We published the 30-day Federal Register Notice on May 27, 2015 at 80 FR 30316. There have been no outside consultations with members of the public.
Payments of Gifts to Respondents
SSA provides no payment 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 information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden Approximately 200,000 respondents will use Form HA-4632 annually. The estimated average response time is 15 minutes, for 50,000 burden hours. The total burden reflects burden hours, and we have not calculated a separate cost burden.
Modality of Completion |
Number of Respondents |
Frequency of Response |
Average Burden per Response (minutes) |
Estimated Total Annual Burden (hours) |
PDF/paper form |
20,000 |
1 |
15 |
5,000 |
Electronic Records Express |
180,000 |
1 |
15 |
45,000 |
Totals |
200,000 |
|
|
50,000 |
There is no known cost burden to the respondents.
Annual Cost to the Federal Government
The annual cost to the Federal Government is approximately $308,000. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
Program Changes or Adjustments to the Information Collection
There are no changes to the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Expiration Date
OMB exempted SSA from publishing the expiration date for OMB approval on its forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB clearance. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). OMB granted this exemption so that SSA would not have to stop using otherwise useable editions of forms with outdated expiration dates. In addition, we avoid government waste because we do not have to destroy and reprint stocks of forms.
Exception 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 did not use statistical methods for this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SUPPORTING STATEMENT FOR FORM HA-4632, |
| Author | 326628 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |