Supporting Statement - 0289 (Final)

Supporting Statement for Form HA-4632

Claimant’s Medications

20 CFR, 404.1512 and 416.912

OMB No. 0960-0289

A. Justification

1. Introduction /Authoring Laws and Regulations

Sections 205(a), 223(d), 702, 1614(a), 1631(e) and 1869(b)(1) of the Social Security Act (Act), as amended, and 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations authorize the Social Security Administration (SSA) to collect the information on Form HA-4632. The Act and the regulations require claimants filing for Social Security, Old Age, Survivors and Disability Insurance (OASDI), or Supplemental Security Income (SSI) payments based on disability, to provide SSA with evidence showing how the claimants' impairment(s) affect their ability to work. The information we request on Form HA-4632 facilitates collecting medical information to support the claimants' applications.

2. Description of Collection

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.

3. Use of Information Technology to Collect the Information

A select population of claimants completes the HA-4632, determined solely at the discretion of the judge based on the conditions of each individual claimant’s hearing. Form HA-4632 is available for the claimants to download and print through our website. For claimants who appoint a representative, SSA allows electronic submission of Form HA-4632 to the claimant’s representative through the Electronic Records Express screens (OMB No. 0960-0753). Appointment of a representative occurs in about 72% of claimant cases. Electronic submission of Form HA‑4632 is not currently available to claimants who do not appoint a representative. Given the individualized nature of the evidence respondents submit, and the intermittent request for this information, SSA prioritized other information collections for full electronic conversions.  Given that IT Mod programming is an ongoing, dynamic project, we cannot provide specific timelines for when we will be able to make any particular ICR available via Internet web-based application.  We will ultimately convert most existing ICRs to full electronic versions depending on how they fall within our overall IT Mod schema, but this may be unconnected to the PRA approval lifecycle. In the interim, we evaluated this collection for conversion to a submittable PDF.  Given the high volume of conversions we are coordinating and the more urgent nature of some of the other conversions, we ultimately decided not to prioritize this ICR for conversion to fully submittable PDF at this time.  When we are able to schedule this form for conversion to a submittable PDF, we will submit a Change Request to OMB to request prior approval.

4. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequences of Not Collecting Information or Collecting it Less Frequently

If we did not use Form HA-4632, it may deprive claimants of their right to present evidence pertaining to their benefit claims causing the agency to violate statutory and regulatory requirements relating to fair hearings and due process. Because we only collect the information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to collect this information in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on August 20, 2021, at

86 FR 46897, and we received no public comments. The 30-day FRN published on October 26, 2021 at 86 FR 59262. If we receive any comments in response to this Notice, we will forward them to OMB.

9. Payments of Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

10. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with

42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

11. Justification for Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollars)*	Average Wait Time in Field Office (minutes) **	Total Annual Opportunity Cost (dollars)***
HA-46321 - PDF/paper version	53,200	1	15	13,300	$10.95*	24**	$378,651***
Electronic Records Express Submissions	136,800	1	15	34,200	$27.07*		$925,794***
Totals	190,000			47,500			$1,304,445***

Note: The above chart breaks down the type of submissions (paper and ERE submissions) for ease of viewing the 72% of respondents who submit via ERE; however, since there is no burden difference for submission type, we did not create separate ICs in ROCIS, opting instead to indicate the 72% in the box provided for Percentage of Respondents Reporting Electronically.

* We based these figures on average DI hourly wages based on SSA's current FY 2020 SSI data (https://www.ssa.gov/legislation/2020%20Fact%20Sheet.pdf); and on average U.S. citizen’s hourly salary, as reported by Bureau of Labor Statistics data (https://www.bls.gov/oes/current/oes_stru.htm).

** We based this figure on averaging both the average FY 2021 wait times for field offices and teleservice centers, based on SSA’s current management information data.

*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

In addition, OMB’s Office of Information and Regulatory Affairs (OIRA) is requiring SSA to use a rough estimate of a 30-minute, one-way, drive time in our calculations of the time burden for this collection. OIRA based their estimation on a spatial analysis of SSA’s current field office locations and the location of the average population centers based on census tract information, which likely represents a 13.97 mile driving distance for one-way travel. We depict this on the chart below:

Total Number of Respondents Who Visit a Field Office	Frequency of Response	Average One-Way Travel Time to a Field Office (minutes)	Estimated Total Travel Time to a Field Office (hours)	Total Annual Opportunity Cost for Travel Time (dollars)****
53,200	1	30	26,600	$291,270

****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

Per OIRA, we include this travel time burden estimate under the 5 CFR 1320.8(a)(4), which requires us to provide “time, effort, or financial resources expended by persons [for]…transmitting, or otherwise disclosing the information,” as well as 5 CFR 1320.8(b)(3)(iii) which requires us to estimate “the average burden collection…to the extent practicable.” SSA notes that we do not obtain or maintain any data on travel times to a field office, nor do we have any data which shows that the average respondent drives to a field office, rather than using any other mode of transport. SSA also acknowledges that respondents’ mode of travel and, therefore, travel times vary widely dependent on region, mode of travel, and actual proximity to a field office.

NOTE: We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates in the paragraph below.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection. Per our management information data, we believe that 15 minutes accurately shows the average burden per response for reading the instructions, gathering the facts, and answering the questions. Based on our current management information data, the current burden information we provided is accurate. The total burden for this collection instrument is 47,500 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $1,595,715. SSA does not charge respondents to complete our applications.

13. Cost to Respondents

This collection does not impose a known cost burden on the respondents.

14. Annual Cost to the Federal Government

The annual cost to the Federal Government is approximately $305,060. This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars
Designing and Printing the Form	Design Cost + Printing Cost	$30,314
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$189,544
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$80,782
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	$0*
Systems Development, Updating, and Maintenance	GS-9 employee x man hours for development, updating, maintenance	$3,420
Quantifiable IT Costs	Any additional IT costs	$0*
Total		$305,060

* We have inserted a $0 amount for cost factors that do not apply to this collection.

SSA is unable to break down the costs to the Federal government further than we already have.  First, since we work with almost every US citizen, we often do bulk mailings, and cannot track the cost for a single mailing.  In addition, it is difficult for us to break down the cost for processing a single form, as field office and hearings office staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent.  As well, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection

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.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Expiration Date

For the paper Form SSA-4632, we will not publish the OMB approval expiration date. OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

For the Internet version of Form SSA-4632 housed under ERE (OMB No. 0960‑0753), SSA is not requesting an exception to the requirement to display the OMB approval expiration date.

18. Exception to Certification Statement

SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA did not use statistical methods for this information collection.

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