Request for Review of Hearing Decision/Order

Forms and Documents

Document Name	Status
Form HA-520 Request for Review of Hearing Decision/Order Form	Modified
Addendum - 0277.docx Supplementary Document	2017-04-28
Supporting Statement - 0277.docx Supporting Statement A	2017-04-28

IC Document Collections

IC ID	Document Title	Status
9181	Request for Review of Hearing Decision/Order Form	Modified

ICR Details

OMB Control No: 0960-0277	ICR Reference No: 201701-0960-008
Status: Historical Active	Previous ICR Reference No: 201509-0960-009
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Review of Hearing Decision/Order
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: 09/29/2017
	Date Received in OIRA: 04/28/2017
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2020	36 Months From Approved	09/30/2017
Responses	175,000	0	171,000
Time Burden (Hours)	29,167	0	28,500
Cost Burden (Dollars)	0	0	0

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Abstract: Claimants have a statutory right under the Social Security Act and implementing regulations to request review of an administrative law judge's (ALJ) hearing decision or dismissal of a hearing request on Title II and Title XVI claims. Claimants may request Appeals Council review by filing a written request using Form HA-520. A completed HA-520 ensures that SSA receives the information to establish the claimant filed the request for review within the prescribed time, and that the claimant has completed the requisite steps to permit review by the Appeals Council. The respondents are claimants requesting review of an ALJ's decision or dismissal of a hearing. We are making nonsubstative changes to Form HA-520 to comply with new regulations regarding submission of evidence.

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Authorizing Statute(s): PL: Pub.L. 106 - 169 809 Name of Law: Foster Care Independence Act of 1999
   US Code: 42 USC 405 Name of Law: The Public Health and Welfare
   US Code: 42 USC 1383 Name of Law: The Public Health and Welfare
   PL: Pub.L. 106 - 169 251 Name of Law: Foster Care Independence Act of 1999
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 10623	02/14/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 18335	04/18/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Review of Hearing Decision/Order	HA-520	Request for Review of Hearing Decision/Order

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ICR Summary 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	175,000	171,000	0	0	4,000	0
Annual Time Burden (Hours)	29,167	28,500	0	0	667	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: The increase in burden hours stems from an increase in the numbers of appeals filed to request a review of hearing decision or order.

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Annual Cost to Federal Government: $336,302

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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

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Common Form ICR:  No

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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: 04/28/2017

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