SUPPORTING STATEMENT FOR FORM HA-4632
CLAIMANT'S MEDICATIONS
20 CFR, 404.1512 and 416.912
OMB No. 0960-0289
A. Justification
1. Introduction/Authoring Laws and Regulations
Sections 205(a), 223(d), 1614(a), and 1631(e) of the Social Security Act (the Act), as amended, and 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations authorize this information collection. The Act and the regulations require that a claimant filing for Social Security, Old Age, Survivors and Disability Insurance (OASDI) or Supplemental Security Income (SSI) payments based on disability must provide the Social Security Administration (SSA) with evidence that shows how the claimant's impairment(s) affects his or her ability to work
2. Description of Collection
In cases where claimants request a hearing after denial of their claim for Social Security benefits, SSA uses Form HA-4632 to obtain information from the claimant about medications they are using. This information helps the administrative law judge overseeing the case to fully investigate (1) the claimant’s medical treatment and (2) the effects for the medications on the claimant’s medical impairment and functional capacity. The respondents are applicants (or their representatives) for Social Security benefits or payments requesting a hearing to contest an agency denial of their claim.
3. Use of Information Technology to Collect the Information
Form HA-4632 is available in a portable document format (PDF) on SSA’s website where claimants can print, fill out, and send or take the completed form to SSA for processing.
For claimants who appoint a representative, electronic submission of Form HA-4632 is available to the claimant’s representative through the Electronic Records Express initiative. Appointment of a representative occurs in about 80% of claimant cases.
4. Why We Cannot Use Duplicate Information
The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar data.
5. Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
6. Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form HA-4632, the agency may deprive claimants of their right to present evidence pertaining to their benefit claims, which would cause the agency to violate statutory and regulatory requirements relating to fair hearings and due process. Because we only collect this information when an ALJ determines it is necessary, we cannot collect it less frequently.
There are no technical or legal obstacles to burden reduction.
Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on April 10, 2012 at
77 FR 21616, and we received no public comments. The 30-day FRN published on June 15, 2012, at 77 FR 36031. If we receive any comments in response to this Notice, we will forward them to OMB.
9. Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
10. Assurances of Confidentiality
SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.
11. Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
12. Estimates of Public Reporting Burden
Collection Instrument |
Number of Respondents |
Frequency of response |
Average burden per response (minutes) |
Estimated total annual burden (hours) |
PDF/paper form |
20,000 |
1 |
15 |
5,000 |
Electronic Records Express |
180,000 |
1 |
15 |
45,000 |
Total |
200,000 |
|
|
50,000 |
The total burden for this ICR is 50,000 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
13. Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden on the respondents.
14. Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $308,000. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
15. Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.
16. Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
18. Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).
B. Collections of Information Employing Statistical Methods
SSA did not use statistical methods for this information collection.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR FORM HA-4632, |
| Author | 326628 |
| Last Modified By | 889123 |
| File Modified | 2012-06-15 |
| File Created | 2012-03-26 |