Medical Report with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-4814 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Available
Form SSA-4814 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Repair queued
Form SSA-4815 Medical Report on Child with Allegation of Human Immunodeficiency virus (HIV) Infection	Form and Instruction	Modified	Available
Form SSA-4815 Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Available
Supporting Statement - 0500 (Final).docx	Supporting Statement A	Uploaded 2022-09-02	Repair queued
Addendum - 0500 (Final).docx	Supplementary Document	Uploaded 2022-08-26	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9396	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection
9396	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified
9396	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Other-Revised PA & PRA Statements	Modified
187514	Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Medical Report on Child with Allegation of Human Immunodeficiency virus (HIV) Infection
187514	Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified
187514	Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	Other-Revised PA & PRA Statements	Modified

ICR Details

OMB Control No: 0960-0500	ICR Reference No: 202204-0960-008
Status: Historical Active	Previous ICR Reference No: 201903-0960-009
Agency/Subagency: SSA	Agency Tracking No:
Title: Medical Report with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/19/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/02/2022
Terms of Clearance: No later than one year prior to resubmission of this information collection for triannual renewal, the agency will evaluate, and share with OMB the reasoning and results of the evaluation, the capacity to electronically receive and process this form through eSubmit or an alternative electronic submission method.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2026	36 Months From Approved	04/30/2023
Responses	1,327	0	9,680
Time Burden (Hours)	598	0	1,293
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses Forms SSA-4814 and SSA-4815 to collect the information necessary to determine if an individual with human immunodeficiency virus (HIV) infection, who is applying for SSI disability payments, meets the requirements for PD. SSA mails the appropriate paper form to the claimant's medical source to complete and return to SSA. Respondents can complete this collection via the paper forms or telephone interview. When respondents complete these forms via telephone interview, which per our Management Information data, is most often, FO or DDS personnel enter the information from the respondents directly into the form, and document the medical source’s name, title, and date in the signature block. We then fax the form into the electronic case file. If SSA FO staff is unable to make a PD finding based on the information the applicant’s medical source provides, the DDS agency makes a determination at their discretion. The respondents are the medical sources of the applicants for SSI disability payments.

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Authorizing Statute(s): 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:
	87 FR 37899	06/24/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 52605	08/26/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	SSA-4814	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection
Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	SSA-4815	Medical Report on Child with Allegation of Human Immunodeficiency virus (HIV) Infection

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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	1,327	9,680	0	0	-8,353	0
Annual Time Burden (Hours)	598	1,293	0	0	-695	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 2019, the burden was 1,293 hours. However, we are currently reporting a burden of 177 hours. This change stems from a decrease in the number of responses from 9,680 to 1,327. 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. Note: The total burden reflected in ROCIS is 598, while the burden cited in #12 of the Supporting Statement is 177. This discrepancy is because the ROCIS burden reflects the following component: teleservice center wait time. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

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Annual Cost to Federal Government: $53,619

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: 09/02/2022

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