Medical Source Statement of Ability to Do Work-Related Activities,

ICR 200608-0960-007

OMB: 0960-0662

Federal Form Document

Forms and Documents
IC Document Collections
ICR Details
0960-0662 200608-0960-007
Historical Active 200602-0960-006
SSA
Medical Source Statement of Ability to Do Work-Related Activities,
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 09/14/2006
Retrieve Notice of Action (NOA) 08/23/2006
  Inventory as of this Action Requested Previously Approved
04/30/2009 04/30/2009 04/30/2009
200,000 0 200,000
50,000 0 50,000
0 0 0

The HA-1151 and HA-1152 are used to collect data that is required to determine the residual functional capacity (RFC) of individuals who are appealing denied claims for benefits based on disability. RFC must be determined to decide cases that cannot be decided based on current work activity or on medical facts alone. The respondents are medical sources that are paid by SSA to provide reports based either on existing medical evidence or on consultative examinations conducted for the purposes of the report.

None
None

Not associated with rulemaking

  71 FR 34181 06/13/2005
No

  Total Approved 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 200,000 200,000 0 0 0 0
Annual Time Burden (Hours) 50,000 50,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Elizabeth Davidson 411-965-0454 liz.davidson@ssa.gov

  No

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.
08/23/2006


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