Supporting Statement - 0500 (Revised)

Supporting Statement for Forms SSA-4814-F5 and SSA-4815-F6

Medical Report on Adult with Allegation of Human

Immunodeficiency Virus Infection;

Medical Report on Child with Allegation of Human

Immunodeficiency Virus Infection

20 CFR 416.933-416.934

OMB No. 0960-0500

A. Justification

1. Introduction/Authoring Laws and Regulations

Section 1633 of the Social Security Act (Act) provides the Commissioner of the Social Security Administration (SSA) with the authority to make administrative and other arrangements to provide Supplemental Security Income (SSI) to disabled individuals. Section 1614(a)(3) of the Act defines when we consider a person to be disabled. Section 1631(e)(1) authorizes the Commissioner to gather information to make a determination about an applicant's claim for SSI payments. Section 1631(a)(4) provides that the Commissioner may pay SSI payments to an applicant for a period not exceeding six months prior to the determination of the individual’s disability, if the individual is presumptively disabled and is determined to be otherwise eligible for benefits; this procedure is called Presumptive Disability (PD). We designed PD payments to provide the applicant with financial support while SSA completes its review of the applicant’s file and the disability claim. Under the provisions of 20 CFR 416.933-416.934 of the Code of Federal Regulations, SSA or State Disability Determination Services (DDS) agencies may make findings of PD if the evidence available at the time reflects a high degree of probability that we will find the individual disabled.

2. Description of the Collection

SSA uses Forms SSA-4814-F5 and SSA-4815-F6 to collect the information necessary to determine if an individual with human immunodeficiency virus (HIV) infection, who is applying for SSI disability payments, meets the requirements for PD. SSA mails the appropriate paper form¹ to the claimant's medical source to complete and return to SSA. If SSA is unable to make a PD finding based on the information the applicant’s medical source provides, the DDS agency is free to do so at its discretion. The respondents are the medical sources of the applicants for SSI disability payments.

3. Use of Information Technology to Collect the Information

SSA created fillable PDF versions of these forms, which are available upon request. We do not make these fillable PDFs available on our website, as we pre-fill Part A of the forms prior to sending them to respondents. In addition, because we pre-fill information, and due to the low volume of respondents for these forms, these forms are not good candidates for electronic implementation.

3. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it preclude duplication. SSA does not use another collection instrument to obtain similar data.

3. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

3. Consequence of Not Collecting Information or Collecting it Less Frequently

If we did not use Forms SSA-4814-F5 and SSA-4815-F6, SSA would not be able to make PD payments for individuals with HIV infections. Because we only collect the information once, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.

3. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

3. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on May 2, 2019, at

84 FR 18913, and we received no public comments. The 30-day FRN published on July 18, 2019 at 84 FR 34469. If we receive any comments in response to this Notice, we will forward them to OMB.

3. Payment of Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

3. 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.

3. Justification for Sensitive Questions

The respondents for these forms provide medical information that is sensitive by its nature. However, SSA needs this information to permit an early PD determination for those individuals alleging HIV infection. Both forms contain an explanation to the respondents that, if they complete the form, their patients may receive early payments. The form includes a signed authorization for release of information by the respondents’ patients.

3. Estimates of Public Reporting Burden

Modality of Completion	Number of Responses	Frequency of Response	Average Burden  Per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-4814-F5	9,600	1	8	1,280
SSA-4815-F6	80	1	10	13
Totals	9,680			1,293

The total burden for this ICR is 1,293 hours. We based these figures on current management information data. This figure represents burden hours, and we did not calculate a separate cost burden.

3. Annual Cost to the Respondents

This collection does not impose a known cost burden on the respondents.

3. Annual Cost to the Federal Government

The annual cost to the Federal government is approximately $71,547. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; and (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time.

3. Program Changes or Adjustments to the Information Collection Request

When we last cleared this IC in 2016, the burden was 2,520 hours. However, we are currently reporting a burden of 1,293 hours. This change stems from a decrease in the number of responses from 18,870 to 9,680 based on current management information data. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change.

3. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms, (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise usable forms with expired OMB approval dates, avoiding Government waste.

17. Exemption to Certification Statement

SSA is not requesting an exception to the certification requirements at

5 CFR 1320.9 and related provisions at 5 CFR 1320.9(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

1 SSA initiates this process when an SSI applicant informs SSA during the application process that they have HIV. Once we complete the initial application (SSA-3368, approved under OMB # 0960‑0579), we send the appropriate paper form to the applicant’s medical source (as provided on the SSA‑3441, OMB # 0960-0144, which all applicants for SSI must complete as part of the application process). We send these forms to medical sources with pre-filled information in Part A (the medical source never needs to fill out Part A). We ask the medical source to return the form via pre-paid envelope (which we include), or return it to an SSA field office.

3