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 SSA requests on Form HA-4632 facilitates collecting medical information to support the claimants' applications.

2. Description of Collection

To receive Old Age Survivors and Disability Insurance (OASDI) and Supplemental Security Income (SSI) benefits, claimants first have their applications adjudicated by the relevant State’s Disability Determination Services office (DDS). If the Field Office (FO) or DDS denies the initial application, the applicant can submit a request for reconsideration of the initial denial. At that time, they can submit further documentation not included with their initial application to further justify their claim. If a DDS denies a claim at the reconsideration level, the claimant has a right to request a hearing before an Administrative Law Judge (ALJ). Before the hearing, SSA, sends the claimant Form HA-4632, and asks the claimant to complete and return Form HA-4632 with the current medications the claimant is presently taking. Judges must obtain this information to update and complete the claimant’s medical record and to verify the accuracy of the information. 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.

We identified the following psychological costs based on the requirements for this information collection:

Psychological Cost #1:

• Requirement for the Program: The HA-4632 provides the judge more information to help decide the claimant’s case.

• Psychological Cost: The claimant might mistakenly perceive that the agency distrusts them and their allegations that they are disabled. Because of this perception, some may find the entire process stressful to the point they may not complete and return the form.

We understand these psychological costs may cause claimants to delay or provide the requested information. However, we require the information on the form to ensure a complete review of the claimant’s disability to determine eligibility for benefits. Therefore, we have taken this potential psychological cost into account when calculating our burden in #12 below.

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. In almost all cases the claimant receives the form in the mail along with a postage paid envelope and a notice explaining the need for a completed HA‑4632 (as well as other forms that may support developing evidence for the case). However, we have also made Form HA-4632 available for the claimants to download from our website and print out, if needed.

For claimants who appoint a representative, SSA allows the claimant’s representative to submit the completed form electronically through the Electronic Records Express (ERE) screens (OMB No. 0960-0753). When the appointed representative uploads and properly labels a form, the system electronically notifies the hearing office that a new document arrived. Appointment of a representative occurs in about 83% of hearing level disability cases; therefore, we receive approximately 83% of these electronically via ERE. Currently, electronic submission of Form HA-4632 is not available to claimants who do not appoint a representative. We are working to create an electronic submission option for this form, but 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, including this one.  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. 

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 SSA did not collect this information, claimants might not present evidence pertinent to their claims for disability payments. As defined in the Act, the HA‑4632 collects medication information necessary for a judge to assess an individual’s treatment, thus creating a legal impediment to reducing the overall burden requirement on the public. As SSA only collects the information when this situation arises, the agency 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 September 12, 2024, at

89 FR 74351, and we received no public comments. The 30-day FRN published on December 2, 2024, at 89 FR 97155. 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

The following chart shows the estimated burden information for the HA-4632:

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-4632 - PDF/paper version 404.1512; 416.912	51,000	1	20	17,000	$13.30*	24**	$497,420***
Electronic Records Express Submissions 404.1512; 416.912	249,000	1	20	83,000	$31.48*		$2,612,840***
Totals	300,000			100,000			$3,110,260***

Note: The above chart breaks down the type of submissions (paper and ERE submissions) for ease of viewing the 83% 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 83% in the box provided for Percentage of Respondents Reporting Electronically.

* We based this figure on the average DI payments based on SSA's current FY 2024 (this is the most current figures we have for the DI payments) data (https://www.ssa.gov/legislation/2024FactSheet.pdf), and on the average U.S. citizen’s hourly salary, as reported by Bureau of Labor Statistics data (https://www.bls.gov/oes/current/oes_nat.htm).

** We based this figure on the average FY 2024 wait times for field offices and hearings office, as well as by averaging both the average FY 2024 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)****
51,000	1	30	25,500	$339,150****

****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.

Note: We did not calculate a separate Learning Cost time burden for this form. Rather, we included a Learning Cost of 5 minutes per response in the above overall burden chart. This Learning Cost it based on the estimated time and effort we expect respondents will take to learn about this program, its applicability to their circumstances, and to cover any additional research we believe respondents may need to take to understand how to comply with the program requirements (beyond reading the instructions on the collection instrument).

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 100,000 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $3,449,410. 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 $316,763. 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	$32,252
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	$196,763
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-9 employee x # of responses x processing time	$84,328
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		$316,763

* 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 2021, the burden was 47,500 hours. However, we are currently reporting a burden of 100,000 hours. This change stems an increase in the number of responses from 200,000 to 300,000 combined with a change in the amount of burden time for response (to include the estimated Learning Costs for this information collection). These figures represent current Management Information data.

* Note: The total burden reflected in ROCIS is 145,900, while the burden cited in #12 of the Supporting Statement is 100,000. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a 30-minute, one-way, drive burden. 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 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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