Supporting Statement for Form HA-4632
Claimant’s Medications
20 CFR, 404.1512 and 416.912
OMB No. 0960-0289
A. Justification
Introduction /Authoring Laws and Regulations
Sections 205(a), 223(d), 702, 1614(a), 1631(e) and 1869(b)(1) of the Social Security Act (Act), as amended, and 20 CFR 404.1512 and 416.912 of the Code of Federal Regulations authorize the Social Security Administration (SSA) to collect the information on Form HA-4632. The Act and the regulations require claimants filing for Social Security, Old Age, Survivors and Disability Insurance (OASDI), or Supplemental Security Income (SSI) payments based on disability, to provide SSA with evidence showing how the claimants' impairment(s) affect their ability to work. The information we request on Form HA-4632 facilitates collecting medical information to support the claimants' applications.
Description of Collection
In cases where claimants request a hearing after denial of their disability claim for Social Security, SSA uses Form HA-4632 to request information from the claimant regarding the medications they use. This information helps the administrative law judge (ALJ) overseeing the case to fully investigate: (1) the claimant’s medical treatment and (2) the effects of the medications on the claimant’s medical impairments and functional capacity. The ALJ makes the completed form a part of the documentary evidence of record, placing it in the official record of the proceedings as an exhibit. The respondents are applicants (or their representatives) for OASDI benefits or SSI payments who request a hearing to contest an agency denial of their claim.
Use of Information Technology to Collect the Information
A select population of claimants completes the HA-4632, determined solely at the discretion of the ALJ based on the conditions of each individual claimant’s hearing. Form HA-4632 is available for the claimants to download and print through our website. For claimants who appoint a representative, SSA allows electronic submission of Form HA-4632 to the claimant’s representative through the Electronic Records Express initiative. Appointment of a representative occurs in about 80% of claimant cases. Electronic submission of Form HA‑4632 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 application under the aegis of the Government Paperwork Elimination Act plan.
Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequences of Not Collecting Information or Collecting it Less Frequently
If we did not use Form HA-4632, it may deprive claimants of their right to present evidence pertaining to their benefit claims causing the agency to violate statutory and regulatory requirements relating to fair hearings and due process. Because we only collect the information on an as needed basis, 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 collect this information 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 24, 2018, at
83 FR 17872, and we received no public comments. The 30-day FRN published on July 10, 2018 at 83 FR 31987. If we receive any comments in response to this Notice, we will forward them to OMB
Payments of Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
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.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Modality of Completion |
Number of Respondents |
Frequency of Response |
Average Burden per Response (minutes) |
Estimated Total Annual Burden (hours) |
HA-4632 (paper) |
20,000 |
1 |
15 |
5,000 |
Electronic Records Express |
180,000 |
1 |
15 |
45,000 |
Totals |
200,000 |
|
|
50,000 |
The total burden for this ICR is 50,000 hours. We based these figures on current management information data. This figure represents burden hours, and we did not calculate a separate cost burden.
Cost to Respondents
This collection does not impose a known cost burden on the respondents.
Annual Cost to the Federal Government
The annual cost to the Federal Government is approximately $308,000. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time; and (3) systems development, updating, and maintenance costs.
Program Changes or Adjustments to the Information Collection
There are no changes to the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Expiration Date
Paper Form
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 that SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
Internet-Based Application
SSA is not requesting an exception to the requirement to display the OMB approval expiration date.
Exception 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/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SUPPORTING STATEMENT FOR FORM HA-4632, |
| Author | 326628 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |