Supporting Statement - 0500 (Final)

Supporting Statement for Forms SSA-4814 and SSA-4815

Medical Report on Adult with Allegation of Human

Immunodeficiency Virus Infection;

Medical Report on Child with Allegation of Human

Immunodeficiency Virus Infection

20 CFR 416.933-416.934

OMB No. 0960-0500

A. Justification

1. Introduction/Authoring Laws and Regulations

Section 1633 of the Social Security Act (Act) provides the Commissioner of the Social Security Administration (SSA) with the authority to make administrative and other arrangements to provide Supplemental Security Income (SSI) to disabled individuals. Section 1614(a)(3) of the Act defines when we consider a person disabled. Section 1631(e)(1) authorizes the Commissioner to gather information to make a determination about an applicant's claim for SSI payments. Section 1631(a)(4) provides that the Commissioner may pay SSI payments to an applicant for a period not exceeding six months prior to the determination of the individual’s disability, if the individual is presumptively disabled and we determine to be otherwise eligible for benefits; we call this procedure Presumptive Disability (PD). We designed PD payments to provide the applicant with financial support while SSA completes its review of the applicant’s file and the disability claim. Under the provisions of 20 CFR 416.933-416.934 of the Code of Federal Regulations, SSA Field Offices (FO) or State Disability Determination Services (DDS) agencies may make findings of PD if the evidence available at the time reflects a high degree of probability that we will find the individual disabled.

2. Description of Collection

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 the paper forms, they return them to SSA via mail. 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. As just mentioned, if respondents complete these forms via telephone interview, we do not require a wet signature. Once we collect all necessary information, we then fax the form into the respondent’s 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.

2. Use of Information Technology to Collect the Information

We created print-only fillable PDF versions of these forms, which are available upon request. SSA has not created a fully electronic version of this information collection at this time, as we send this agency-initiated application to respondents with pre-filled information.  We also include a bar code which allows us to scan the completed form into the electronic folder once we receive it from the respondent.  Currently, we do not have any means to pre-fill information and send the individualized forms to the respondents electronically, as that would require us to build a new system, and we do not have the resources and manpower to do that at this time.  In addition, we cannot send these via email, as the pre-filled information contains personal identifying information (PII) of the respondents, and email is a non-secured means of transferring PII.  We will reassess our ability to create an electronic version of this collection if and when technological advances are created that would allow for us to make this collection available via the Internet in a fully secure way.

In the interim, we evaluated this collection for conversion to a submittable PDF.  Given the high volume of conversions we are coordinating, the more urgent nature of some of the other conversions, and the additional work we need to do to convert this pre-filled form to a submittable PDF, 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.

2. 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. Consequence of Not Collecting Information or Collecting it Less Frequently

If we did not use Forms SSA-4814 and SSA-4815, SSA FO and DDS staff would not be able to make PD determinations or payments for individuals with HIV infections. Because we only collect the information once, 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 conduct this information collection 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 June 24, 2022, at 87 FR 37899, and we received no public comments. The 30-day FRN published on August 26, 2022, at 87 FR 52605. If we receive any comments in response to this Notice, we will forward them to OMB.

8. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

8. 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.

8. Justification for Sensitive Questions

The respondents for these forms provide medical information that is sensitive in nature. However, SSA needs this information to permit SSA FO and DDS staff to make an early PD determination for those individuals alleging HIV infection.

8. Estimates of Public Reporting Burden

Please see the burden chart below:

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 for Teleservice Centers (minutes) **	Total Annual Opportunity Cost (dollars)***
SSA-4814	1,307	1	8	174	$16.02*	19**	$9,420***
SSA-4815	20	1	10	3	$16.02*	19**	$144***
Totals	1,327			177			$9,564***

* We based this figure on the average Healthcare Support Occupations, as reported by Bureau of Labor Statistics data (https://www.bls.gov/oes/current/oes310000.htm).

** We based this figure on the average FY 2022 wait times for 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.

NOTE: We did not include travel time as per our current management information data, respondents who complete the paper forms return them to us via mail. Should this change in the future, we will include the language and chart for travel time to a field office.

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 the 8 and 10 minutes shown in our chart above 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 ICR is 177 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $9,564. SSA does not charge respondents to complete our applications.

13. Annual Cost to the Respondents (Other)

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

14. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $53,619. 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	$1,595
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$0*
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-11/12 employee x # of responses x processing time	$45,184
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	$6,840
Quantifiable IT Costs	Any additional IT costs	$0*
Total		$53,619

* 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.  It is difficult for us to break down the cost for processing a single form, as FO and State DDS 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 both GS-11 and GS-12 employees have a hand in each aspect of these forms, we use an estimated average hourly wage, based on an average of the GS‑11 and GS-12 employee wages 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 Request

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.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying 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.

18. Exceptions 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 does not use statistical methods for this information collection.