Medical Source Statement of Ability to Do Work-Related Activities

ICR 201611-0960-004

OMB: 0960-0662

Federal Form Document

ICR Details
0960-0662 201611-0960-004
Historical Active 201406-0960-011
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 12/06/2016
Retrieve Notice of Action (NOA) 11/29/2016
  Inventory as of this Action Requested Previously Approved
10/31/2017 10/31/2017 10/31/2017
300,000 0 300,000
75,000 0 75,000
0 0 0

SSA uses Forms HA-1151 and HA-1152 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. The RFC of an individual must be determined in cases where SSA cannot make a determination on a claim for benefits based on current work activity or on medical facts alone. The respondents are medical sources paid by SSA to provide reports based either on existing medical evidence or on consultative examinations conducted for the purposes of the report. This Non-Substantive Change Request makes minor language revisions to the HA-1152 based on the Final Rule, RIN 0960-AF69, published on September 26, 2016 at 81 FR 66137 (see Justification Statement for more information).

US Code: 42 USC 1381 Name of Law: Social Security Act
   US Code: 42 USC 902 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  79 FR 38107 07/03/2014
79 FR 56428 09/19/2014
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 300,000 300,000 0 0 0 0
Annual Time Burden (Hours) 75,000 75,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$9,000
No
No
No
No
No
Uncollected
Faye Lipsky 410 965-8783 faye.lipsky@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.
11/29/2016


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