Request to Withdraw a Hearing Request; Request to Withdraw an Appeals Council Request for Review; and Administrative Review Process for Adjudicating Initial Disability Claims

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form e85 Request to Withdraw a Hearing Request	Form and Instruction	Modified	Available
Form HA-86 Request to Withdraw an Appeals Council Request for Review	Form	Modified	Available
Form HA-85 Request to Withdraw a Hearing Request	Form	Modified	Available
Form HA-85 20 CFR 404.971 and 416.1471 (HA-85, Request to Withdraw a Hearing Request; HA-86, Request to Withdraw an Appeals Council Request for Review)	Form	Modified	Repair queued
Justification for Non-Substantive Changes - 0710 (IT Mod Request).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-06-16	Repair queued
Supporting Statement - 0710.docx	Supporting Statement A	Uploaded 2019-09-23	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9767	20 CFR 404.961, 416.1461, 405.330, 405.366		Unchanged
237195	20 CFR 404.1512, 404.1740(c)(4), 416.912, and 416.1540(c)(4)		Unchanged
237194	20 CFR 1540(b)(1)		Unchanged
237193	20 CFR 404.1740(b)(1)		Unchanged
206582	20 CFR 404.971 and 416.1471 (HA-85, Request to Withdraw a Hearing Request; HA-86, Request to Withdraw an Appeals Council Request for Review)	Form and Instruction	Modified	Request to Withdraw a Hearing Request
206582	20 CFR 404.971 and 416.1471 (HA-85, Request to Withdraw a Hearing Request; HA-86, Request to Withdraw an Appeals Council Request for Review)	Form	Modified	Request to Withdraw an Appeals Council Request for Review
206582	20 CFR 404.971 and 416.1471 (HA-85, Request to Withdraw a Hearing Request; HA-86, Request to Withdraw an Appeals Council Request for Review)	Form	Modified	Request to Withdraw a Hearing Request
206582	20 CFR 404.971 and 416.1471 (HA-85, Request to Withdraw a Hearing Request; HA-86, Request to Withdraw an Appeals Council Request for Review)	Form	Modified
197304	20 CFR 405.20		Unchanged
197303	20 CFR 405.1(c)(2)		Unchanged
197302	20 CFR 405.505		Unchanged
197301	20 CFR 405.1(b)(5) and 405.372(b)		Unchanged
197300	20 CFR 405.372(c)		Unchanged
197299	20 CFR 405.401		Unchanged
187625	20 CFR 404.987 & 404.988, 416.1487 & 4161488, and 405.601		Unchanged
187624	20 CFR 404.982 & 416.1482		Unchanged
187622	20 CFR 405.381		Unchanged
187620	20 CFR 404.957, 416.1457, 405.380		Unchanged
187619	20 CFR 405.334		Unchanged
187618	20 CFR 404.949 and 416.1449		Unchanged
187617	20 CFR 404.950, 416.1450, 405.332		Unchanged

ICR Details

OMB Control No: 0960-0710	ICR Reference No: 202106-0960-002
Status: Historical Active	Previous ICR Reference No: 202011-0960-009
Agency/Subagency: SSA	Agency Tracking No:
Title: Request to Withdraw a Hearing Request; Request to Withdraw an Appeals Council Request for Review; and Administrative Review Process for Adjudicating Initial Disability Claims
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/25/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/17/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2022	12/31/2022	12/31/2022
Responses	76,300	0	76,300
Time Burden (Hours)	22,548	0	22,548
Cost Burden (Dollars)	0	0	0

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Abstract: Claimants have a statutory right under the Act and current regulations to apply for Social Security DIB or SSI payments. SSA must collect information from each step of the administrative review process to adjudicate claims fairly and efficiently. SSA collects this information to establish a claimant’s right to administrative review and the severity of the claimant’s alleged impairments. SSA uses the information to determine entitlement or continuing eligibility to DIB or SSI payments, and to enable appeals of these determinations. The respondents are applicants for Title II DIB or Title XVI SSI payments; their appointed representatives; legal advocates; medical sources; and schools. This is an IT Modification Change Request to include a fillable and submittable modality for the HA-85 under this ICR. The fillable and submittable version mirrors the current paper form.

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Authorizing Statute(s): 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:
	84 FR 31972	07/03/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 48694	09/16/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 18

table that charts list of burden

IC Title	Form No.	Form Name
20 CFR 1540(b)(1)
20 CFR 404.1512, 404.1740(c)(4), 416.912, and 416.1540(c)(4)
20 CFR 404.1740(b)(1)
20 CFR 404.949 and 416.1449
20 CFR 404.950, 416.1450, 405.332
20 CFR 404.957, 416.1457, 405.380
20 CFR 404.961, 416.1461, 405.330, 405.366
20 CFR 404.971 and 416.1471 (HA-85, Request to Withdraw a Hearing Request; HA-86, Request to Withdraw an Appeals Council Request for Review)	HA-85, HA-86, e85	Request to Withdraw a Hearing Request ,   Request to Withdraw an Appeals Council Request for Review ,   Request to Withdraw a Hearing Request
20 CFR 404.982 & 416.1482
20 CFR 404.987 & 404.988, 416.1487 & 4161488, and 405.601
20 CFR 405.1(b)(5) and 405.372(b)
20 CFR 405.1(c)(2)
20 CFR 405.20
20 CFR 405.334
20 CFR 405.372(c)
20 CFR 405.381
20 CFR 405.401
20 CFR 405.505

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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	76,300	76,300	0	0	0	0
Annual Time Burden (Hours)	22,548	22,548	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: $500

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: 06/17/2021

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