Claimant's Work Background

Forms and Documents

Document Name	Status
Form HA-4633 HA-4633 - Paper Version Form	Modified
Form HA-4633 HA-4633 - Electronic Records Express Submissions Form and Instruction	New
Addendum - 0300.docx Supplementary Document	2020-08-21
Supporting Statement - 0300.docx Supporting Statement A	2020-08-21

IC Document Collections

IC ID	Document Title	Status
9205	HA-4633 - Paper Version Form	Modified
243285	HA-4633 - Electronic Records Express Submissions Form and Instruction	New

ICR Details

OMB Control No: 0960-0300	ICR Reference No: 202007-0960-003
Status: Received in OIRA	Previous ICR Reference No: 201702-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Claimant's Work Background
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/21/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2021
Responses	190,000	200,000
Time Burden (Hours)	47,500	50,000
Cost Burden (Dollars)	0	0

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Abstract: Form HA-4633 collects information needed in assessing an individual's disability within the meaning of the Social Security Act(the Act). SSA uses the information when an individual has requested a hearing before an administrative law judge (ALJ) on whether or not he or she is disabled. The completed HA-4633 provides an updated summary of the individual's relevant work history, which is information the ALJ requires in assessing the claimant's disability within the meaning of the Act. The respondents are claimants for disability benefits under Title II and/or Title XVI who have requested a hearing before an ALJ.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 1383 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:
	85 FR 37996	06/24/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 51536	08/20/2020
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
HA-4633 - Paper Version	HA-4633	Claimant's Work Background
HA-4633 - Electronic Records Express Submissions	HA-4633	Claimant’s Work Background

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ICR Summary of Burden

	Total Request	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	190,000	200,000	0	0	-10,000	0
Annual Time Burden (Hours)	47,500	50,000	0	0	-2,500	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: When we last cleared this IC in 2017, the burden was 50,000 hours. However, we are currently reporting a burden of 47,500 hours. This change stems a decrease in the number of responses from 200,000 to 190,000. 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. These figures represent current Management Information data.

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Annual Cost to Federal Government: $383,460

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? No

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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: 08/21/2020

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