View Information Collection (IC)

View Information Collection (IC)

IC Title:	Medical Source Statement of Ability to Do Work-Related Activities (Mental) - SSA-1152	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.912 - 416.913 20 CFR 416.917 20 CFR 404.1512 - 404.1513 20 CFR 404.1517

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-1152	Medical Source Statement of Ability to Do Work-Related Activity (Mental)	HA-1152 - Revised Version.pdf		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	150,000	0	0	0	0	150,000
Annual IC Time Burden (Hours)	37,500	0	0	0	0	37,500
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current HA-1152	HA-1152 - Current Version.pdf	01/28/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.