Supporting Statement - 0300

Supporting Statement for Form HA-4633

Claimant’s Work Background

20 CFR 404.1512(a); 404.1520(a)(4); 404.1565(b)

and 20 CFR 416.912(a); 416.920(a)(4); 416.965(b)

OMB No. 0960-0300

A. Justification

1. Introduction/Authoring Laws and Regulations

Sections 205(a) and 1631(e) of the Social Security Act (Act) provide the Commissioner of Social Security with the authority to establish procedures for determining whether a claimant is entitled to disability benefits. The Social Security Administration (SSA) may ask individuals who apply for disability benefits under the Act to provide background information about work they performed in the past 15 years, as prescribed in 20 CFR, 404.1512(a), 404.1565(b),416.912(a) and 416.965(b) of the Code of Federal Regulations. Form HA‑4633 facilitates the collection of a claimant’s work background. If SSA finds the claimants to be disabled without consideration of their work history, the administrative law judge (ALJ) does not require completion of the Form HA-4633, as per 20 CFR 404.1520(a)(4) and 416.920(a)(4).

2. Description of Collection

When a claimant requests a hearing before an ALJ to establish an entitlement to disability benefits, the ALJ may request that the claimant provide a work history to assist the ALJ in fully inquiring into statutory issues related to the disability. The ALJ uses the information collected from the claimants on Form HA-4633 to: (1) identify the claimant’s relevant work history; (2) decide if expert vocational testimony is required and, if so, have a vocational expert available to testify during the hearing; and (3) provide a reference for the ALJ to discuss the claimant’s work history. The ALJ makes the completed HA-4633 part of the documentary evidence of record. The respondents are claimants for disability benefits under Title II or Title XVI who requested a hearing before an ALJ after SSA denied their application for disability payments.

3. Use of Information Technology to Collect the Information

A select population of claimants completes The HA-4633, determined solely at the discretion of the ALJ, and based on the conditions of each individual claimant’s hearing. SSA provides a PDF version of the HA-4633 form for download and printing by the claimants on the internet at http://www.ssa.gov/online/ha-4633.html.

For claimants who appoint a representative, SSA allows the claimant’s representative to submit the completed form electronically through the Electronic Records Express (ERE) initiative (OMB No. 0960-0753). Appointment of a representative occurs in about 80% of claimant cases. Electronic submission of Form HA-4633 is not available to claimants who do not appoint a representative. Given the individualized nature of the evidence respondents submit and the intermittent request for this information, SSA did not deem it appropriate to develop an electronic form under the aegis of the Government Paperwork Elimination Act plan.

4. Why We Cannot Use Duplicate Information

The nature of the information SSA collects and the manner in which we collect it differs from work background collected at the initial and reconsideration adjudicative levels. SSA does not have another collection instrument that brings together the data on the HA‑4633.

4. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

4. Consequence of Not Collecting Information or Collecting it Less Frequently

SSA collects the information from an individual one time, and only if the ALJ hearing the case decides it is necessary. If SSA did not collect this information, a claimant might not present evidence pertinent to his or her claim for disability benefits. As defined in the Act, the HA-4633 collects the minimum information necessary for an ALJ to assess an individual’s work history thus creating a legal impediment to reducing the overall burden requirement on the public. Since SSA collects the information only when this situation arises, the agency cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to collect this information in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on April 16, 2014, at 79 FR 21499, and we received no public comments. SSA published the second Notice on July 2, 2014, at 79 FR 37828. If we receive comments in response to the 30-day Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.

9. Payment or Gifts to Respondents

SSA provides no payment or gifts to the respondents.

10. Assurances of Confidentiality

SSA protects and holds confidential the information from this form 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

This information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

Approximately 200,000 respondents use Form HA-4633 annually. The estimated average response time is 15 minutes, for a total burden of 50,000 hours. This figure represents burden hours and we did not calculate a separate cost burden.

Note: The following chart breaks out the type of submissions (paper and ERE submissions) for ease of viewing the 80% of respondents who submit via ERE; however, since there is no burden difference for submission type, we did not create separate ICs in ROCIS, opting instead to indicate the 80% in the box provided for Percentage of Respondents Reporting Electronically.

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Estimated Total Annual Burden (hours)
HA-4633 - PDF/paper version	20,000	1	15	5,000
Electronic Records Express Submissions	180,000	1	15	45,000
Total	200,000			50,000

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 $1,162,700. This estimate is a projection of printing and distribution expenditures for the form and the cost of 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 collected.

17. Displaying the OMB Approval Expiration Date

For the paper Form SSA-4633, we will not publish 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.

For the Internet version of Form SSA-4633 housed under ERE (OMB No. 0960‑0753), SSA is not requesting an exception to the requirement to display the OMB approval expiration date .

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 does not use statistical methods for this collection.