Claimant's Medications

Forms and Documents

Document Name	Status
Form HA-4632 Claimant's Medication - PDF/Paper Version Form	Modified
Addendum - 0289 (Final).docx Supplementary Document	2021-11-02
Supporting Statement - 0289 (Final).docx Supporting Statement A	2021-11-02

IC Document Collections

IC ID	Document Title	Status
43700	Claimant's Medication - PDF/Paper Version Form	Modified
189495	Claimant's Medications - ERE Internet Version Other-Internet Screens	Modified

ICR Details

OMB Control No: 0960-0289	ICR Reference No: 202111-0960-001
Status: Received in OIRA	Previous ICR Reference No: 201804-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Claimant's Medications
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/02/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	11/30/2021
Responses	190,000	200,000
Time Burden (Hours)	47,500	50,000
Cost Burden (Dollars)	0	0

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Abstract: In cases where claimants request a hearing after denial of their disability claim for Social Security, SSA uses Form HA-4632 to request information from the claimant regarding the medications they use. This information helps the judge overseeing the case to fully investigate: (1) the claimant’s medical treatment and (2) the effects of the medications on the claimant’s medical impairments and functional capacity. The judge makes the completed form a part of the documentary evidence of record, placing it in the official record of the proceedings as an exhibit. The respondents are applicants (or their representatives) for OASDI benefits or SSI payments who request a hearing to contest an agency denial of their claim.

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Authorizing Statute(s): US Code: 42 USC 405 Name of Law: Social Security Act
   US Code: 42 USC 423 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:
	86 FR 46897	08/20/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 59262	10/26/2021
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
Claimant's Medication - PDF/Paper Version	HA-4632	Claimant's Medications
Claimant's Medications - ERE Internet Version	HA-4632	Claimant's Medications

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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 2018, 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: $305,060

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: 11/02/2021

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