Request for Hearing By Administrative Law Judge

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form HA-501 Request for Hearing By Administrative Law Judge--Paper/MCS/MSSICS Versions	Form and Instruction	Modified	Available
iAppeals Single Submission Conference Call Notes 10-13-16.doc	Supplementary Document	Uploaded 2016-10-21	Available
iAppeals Single Submission Conference Call Notes 2-22-16.doc	Supplementary Document	Uploaded 2016-10-21	Available
Addendum - 0269.docx	Supplementary Document	Uploaded 2016-10-21	Available
Supporting Statement - 0269.docx	Supporting Statement A	Uploaded 2016-10-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9174	Request for Hearing By Administrative Law Judge--Paper/MCS/MSSICS Versions	Form and Instruction	Modified
180726	Request for Hearing By Administrative Law Judge--Internet Version (i501)	Other-Internet Screens	Modified

ICR Details

OMB Control No: 0960-0269	ICR Reference No: 201607-0960-004
Status: Historical Active	Previous ICR Reference No: 201404-0960-015
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Hearing By Administrative Law Judge
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: 11/21/2016
	Date Received in OIRA: 10/21/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2019	36 Months From Approved	10/31/2017
Responses	669,469	0	669,469
Time Burden (Hours)	56,702	0	57,952
Cost Burden (Dollars)	0	0	0

---

Abstract: When SSA denies applicants' or beneficiaries' requests for new or continuing benefits, those applicants or beneficiaries are entitled to request a hearing to appeal the decision. To request a hearing, individuals use Form HA–501, the associated Modernized Claims System (MCS) or Modernized Supplemental Security Income Claims System (MSSICS) interview, or the Internet application (i501). SSA uses the information to determine if the individual filed the request within the prescribed time; is the proper party; and has taken the steps necessary to obtain the right to a hearing. SSA also uses the information to determine the individual's reason(s) for disagreeing with SSA's prior determinations in the case; if the individual has additional evidence to submit; if the individual wants an oral hearing or a decision on-the-record; and whether the individual has (or wants to appoint) a representative. The respondents are Social Security benefit applicants and recipients who want to appeal SSA's denial of their request for new or continued benefits and Medicare Part B recipients who must pay the Medicare Part B Income-Related Monthly Adjustment Amount.

---

Authorizing Statute(s): PL: Pub.L. 106 - 169 251 & 809 Name of Law: Foster Care Independence Act of 1999
   US Code: 42 USC 1320c-4 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act
   US Code: 42 USC 1395ff Name of Law: Social Security Act
   US Code: 42 USC 1395r Name of Law: Social Security Act
   PL: Pub.L. 108 - 173 1350 & 931 Name of Law: Medicare Modernization Act of 2003
   PL: Pub.L. 103 - 296 105(a)(2)(B) Name of Law: Social Security Independence and Program Improvements Act
   US Code: 42 USC 405 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:
	81 FR 47845	07/22/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 68088	10/03/2016
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
Request for Hearing By Administrative Law Judge--Internet Version (i501)
Request for Hearing By Administrative Law Judge--Paper/MCS/MSSICS Versions	HA-501	Request for Hearing By Administrative Law Judge

---

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	669,469	669,469	0	0	0	0
Annual Time Burden (Hours)	56,702	57,952	0	-1,250	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The decrease in burden hours stems from SSA updating the iAppeals application by adding the function for individuals to file a non-medical appeal through iAppeals by using the i561 (Request for Reconsideration; OMB # 0960-0622) or the i501 Request for Hearing by Administrative Law Judge. Currently, individuals may only appeal medical decisions using the i561 or i501 and i3441 (Disability Report; OMB # 0960-0144), by including non-medical appeals to the iAppeals process, we allow individuals who would have used the more lengthy paper process to use our shorter electronic process instead.

---

Annual Cost to Federal Government: $55,000

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: 10/21/2016

---