Medical Report with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child

Forms and Documents

Document	Type	Status	Availability
Form SSA-4814 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Available
Form SSA-4815 Medical Report on Child with Allegation of Human Immunodeficiency virus (HIV) Infection	Form and Instruction	Modified	Available
Addendum - 0500.docx	Supplementary Document	Uploaded 2026-04-28	Available
Supporting Statement - 0500.docx	Supporting Statement A	Uploaded 2026-04-28	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
9396	SSA-4814 - Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection
187514	SSA-4815 - Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Medical Report on Child with Allegation of Human Immunodeficiency virus (HIV) Infection

ICR Details

OMB Control No: 0960-0500	ICR Reference No: 202603-0960-007
Status: Received in OIRA	Previous ICR Reference No: 202306-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Medical Report with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 04/28/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2026
Responses	840	1,327
Time Burden (Hours)	225	598
Cost Burden (Dollars)	0	0

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Abstract: 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 source’s 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 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. 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.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 9671	02/26/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 22195	04/24/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
SSA-4814 - Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	SSA-4814	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection
SSA-4815 - Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	SSA-4815	Medical Report on Child with Allegation of Human Immunodeficiency virus (HIV) Infection

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	840	1,327	0	0	-487	0
Annual Time Burden (Hours)	225	598	0	0	-373	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: 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.

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Annual Cost to Federal Government: $11,881

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/28/2026

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