Medical Source Statement of Ability to Do Work-Related Activities

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form HA-1151-BK Medical Source Statement of Ability to Do Work-Related Activities (Physical)	Form	Modified	Available
Form HA-1151-BK Medical Source Statement of Ability To Do Work-Related Activities (Physical) - SSA-1151	Form	Modified	Available
Form HA-1152 Medical Source Statement of Ability to Do Work-Related Activity (Mental)	Form	Modified	Available
Form HA-1152 Medical Source Statement of Ability to Do Work-Related Activities (Mental) - SSA-1152	Form	Modified	Available
Supporting Statement - 0662.docx	Supporting Statement A	Uploaded 2021-01-28	Repair queued
Addendum - 0662.docx	Supplementary Document	Uploaded 2021-01-28	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9709	Medical Source Statement of Ability To Do Work-Related Activities (Physical) - SSA-1151	Form	Modified	Medical Source Statement of Ability to Do Work-Related Activities (Physical)
9709	Medical Source Statement of Ability To Do Work-Related Activities (Physical) - SSA-1151	Form	Modified
9709	Medical Source Statement of Ability To Do Work-Related Activities (Physical) - SSA-1151	Other-Revised PA Statement	Modified
188400	Medical Source Statement of Ability to Do Work-Related Activities (Mental) - SSA-1152	Form	Modified	Medical Source Statement of Ability to Do Work-Related Activity (Mental)
188400	Medical Source Statement of Ability to Do Work-Related Activities (Mental) - SSA-1152	Form	Modified

ICR Details

OMB Control No: 0960-0662	ICR Reference No: 202101-0960-006
Status: Historical Active	Previous ICR Reference No: 201704-0960-009
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: 07/27/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/28/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2024	36 Months From Approved	07/31/2021
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: When a claimant appeals a denied disability claim, SSA may ask the claimant to have a consultative examination at the agency’s expense, if the claimant’s medical sources cannot, or will not, give the agency sufficient evidence to determine whether the claimant is disabled. The medical providers who perform these consultative examinations provide a statement about the claimant’s state of disability. Specifically, these medical source statements determine the work-related capabilities of these claimants. SSA collects the medical data on the HA-1151 and HA-1152 to assess the work-related physical and mental capabilities of claimants who appeal SSA’s previous determination on their issue of disability. The respondents are medical sources who provide reports based either on existing medical evidence or on consultative examinations.

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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:
	85 FR 76142	11/27/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 7446	01/28/2021
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Medical Source Statement of Ability To Do Work-Related Activities (Physical) - SSA-1151	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) - SSA-1152	HA-1152	Medical Source Statement of Ability to Do Work-Related Activity (Mental)

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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	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: $336,387

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: 01/28/2021

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