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Medical Source Statement of Ability To Do Work-Related Activities (Physical) - SSA-1151

IC 9709 under ICR 202501-0960-003 · OMB 0960-0662.

Documents and Forms
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Document Type
Form
Other-Revised PA Statement
Other-Revised PA Statement
Form
Form
IC Document
IC Document
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Medical Source Statement of Ability To Do Work-Related Activities (Physical) - SSA-1151
 
No Unchanged
 
Voluntary
 
20 CFR 404.1517 20 CFR 416.912 - 416.913 20 CFR 416.917 20 CFR 404.1512 - 404.1513

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form HA-1151-BK Medical Source Statement of Ability to Do Work-Related Activities (Physical) HA-1151-BK (revised).pdf No   Paper Only
Other-Revised PA Statement Privacy Act Statement (revised).docx No   Paper Only

Income Security General Retirement and Disability

 

5,000 0
   
State, Local, and Tribal Governments
 
   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-1151-BK (current) HA-1151-BK (current).pdf 07/03/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.