Information Collection

Medical Source Statement of Ability To Do Work-Related Activities (Physical) - SSA-1151

IC 9709 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⚠️ Notice: This information collection may be referencing outdated material.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-1151-BK Medical Source Statement of Ability To Do Work-Related Activities (Physical) - SSA-1151	Form
Revised PA Statement.pdf	Other-Revised PA Statement
Revised PA Statement.pdf	Other-Revised PA Statement
HA-1151-BK Medical Source Statement of Ability to Do Work-Related A HA-1151 - Revised Version.pdf	Form
HA-1151-BK Medical Source Statement of Ability to Do Work-Related A HA-1151 - Revised Version.pdf	Form
HA-1151 - Current Version.pdf Current HA-1151	IC Document
HA-1151 - Current Version.pdf Current HA-1151	IC Document

IC Title:

Medical Source Statement of Ability To Do Work-Related Activities (Physical) - SSA-1151

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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

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-1151-BK	Medical Source Statement of Ability to Do Work-Related Activities (Physical)	HA-1151 - Revised Version.pdf		No		Paper Only
Other-Revised PA Statement			Revised PA Statement.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: State, Local, and Tribal Governments

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-1151	HA-1151 - Current Version.pdf	01/28/2021

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