Medical Report with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child
Revision of a currently approved collection
No
Regular
Approved without change
09/16/2026
04/28/2026
table that charts list comparision
Inventory as of this Action
Requested
Previously Approved
09/30/2029
36 Months From Approved
09/30/2026
840
0
1,327
225
0
598
0
0
0
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 sourceâs 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 applicantâs 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.
We are updating all the fields where we request date on Form SSA-4814 and SSA-4815. We are adding an arrow on the side where the respondent can pull up a calendar and select the date (the respondent can still type in the date in any format they choose). We are also revising the date format from December 2, 2015 to 12/2/2015.
US Code:
42 USC 1383
Name of Law: Social Security Act
When we last cleared this IC in 2023, the burden was 177 hours. However, we are currently reporting a burden of 155 hours. This change stems from a decrease in the number of responses from 1,327 to 840. Although the number of responses changed, SSA did not take any actions to cause this change. In addition, we updated the completion time from 8 to 11 minutes for the SSA-4814 and from 10 to 13 minutes for the SSA-4815. We made this correction based on our estimate for the psychological costs on the respondents.
* Note: The total burden reflected in ROCIS is 225, while the burden cited in #12 of the Supporting Statement is 155. This discrepancy is because the ROCIS burden reflects learning costs in addition to the completion and psychological costs. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.
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:
(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;
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.
Form SSA-4814 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection
Addendum - 0500.docx
SSA-4814 - Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection