Information Collection

Medical Source Statement of Ability to Do Work-Related Activities (Mental) - SSA-1152

IC 188400 under ICR 202101-0960-006 · OMB 0960-0662.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0662 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HA-1152 Medical Source Statement of Ability to Do Work-Related Activities (Mental) - SSA-1152	Form
HA-1152 Medical Source Statement of Ability to Do Work-Related A HA-1152 - Revised Version.pdf	Form
HA-1152 Medical Source Statement of Ability to Do Work-Related A HA-1152 - Revised Version.pdf	Form
HA-1152 - Current Version.pdf Current HA-1152	IC Document
HA-1152 - Current Version.pdf Current HA-1152	IC Document

IC Title:

Medical Source Statement of Ability to Do Work-Related Activities (Mental) - SSA-1152

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.912 - 416.913 20 CFR 416.917 20 CFR 404.1512 - 404.1513 20 CFR 404.1517

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-1152	Medical Source Statement of Ability to Do Work-Related Activity (Mental)	HA-1152 - Revised Version.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	150,000	150,000
Annual IC Time Burden (Hours)	37,500	37,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current HA-1152	HA-1152 - Current Version.pdf	01/28/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.