Medical Source Statement of Ability to Do Work-Related Activities

Forms and Documents

Document Name	Status
Form HA-1151-BK Medical Source Statement of Ability To Do Work-Related Activities (Physical) Form	Modified
Form HA-1152 Medical Source Statement of Ability to Do Work-Related Activities (Mental) Form	Modified
Supporting Statement - 0662.docx Supporting Statement A	2017-09-01
Addendum - 0662.docx Supplementary Document	2017-08-22

IC Document Collections

IC ID	Document Title	Status
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: 201704-0960-009
Status: Active	Previous ICR Reference No: 201611-0960-004
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: 02/28/2018
	Date Received in OIRA: 09/01/2017
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	02/28/2021	36 Months From Approved	02/28/2018
Responses	300,000	0	300,000
Time Burden (Hours)	75,000	0	75,000
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): US Code: 42 USC 1381 Name of Law: Social Security Act
   US Code: 42 USC 902 Name of Law: Social Security Act
  

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 22173	05/12/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 38982	08/16/2017
Did the Agency receive public comments on this ICR? No

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

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

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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	300,000	300,000	0	0	0	0
Annual Time Burden (Hours)	75,000	75,000	0	0	0	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:

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Annual Cost to Federal Government: $9,000

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: 09/01/2017

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