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Federal forms, ICRs, and supporting documents

Information Collection

Medical Source Statement of Ability to Do Work-Related Activities (Mental) - SSA-1152

IC 188400 under ICR 202501-0960-003 · OMB 0960-0662.

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Medical Source Statement of Ability to Do Work-Related Activities (Mental) - SSA-1152
 
No Unchanged
 
Required to Obtain or Retain Benefits
 
20 CFR 404.1512 - 404.1513 20 CFR 404.1517 20 CFR 416.912 - 416.913 20 CFR 416.917

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form HA-1152 Medical Source Statement of Ability to Do Work-Related Activity (Mental) HA-1152-U3 (revised).pdf No   Paper Only

Income Security General Retirement and Disability

 

5,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 150,000 0 0 0 0 150,000
Annual IC Time Burden (Hours) 37,500 0 0 0 0 37,500
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
HA-1152-U3 (current) HA-1152-U3 (current).pdf 07/03/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.