View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0960-0500
ICR Reference No:
201701-0960-014
Status:
Historical Active
Previous ICR Reference No:
201604-0960-003
Agency/Subagency:
SSA
Agency Tracking No:
Title:
Medical Report with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
05/11/2017
Retrieve Notice of Action (NOA)
Date Received in OIRA:
02/08/2017
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
08/31/2019
08/31/2019
08/31/2019
Responses
18,870
0
18,870
Time Burden (Hours)
2,520
0
2,520
Cost Burden (Dollars)
0
0
0
Abstract:
SSA uses Forms SSA-4814-F5 and SSA-4815-F6 to collect information necessary to determine if an individual with HIV, who is applying for SSI disability benefits, meets the requirements for presumptive disability payments. The respondents are the medical sources of the applicants for SSI disability payments. We are making Non-Substantive changes to the forms to make them consistently formatted throughout.
Authorizing Statute(s):
US Code:
42 USC 1383
Name of Law: Social Security Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
81 FR 19283
04/04/2016
30-day Notice:
Federal Register Citation:
Citation Date:
81 FR 39990
06/20/2016
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection
SSA-4814-F5
Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection
Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection
SSA-4815-F6
Medical Report on Child with Allegation of Human Immunodeficiency virus (HIV) Infection
ICR Summary of Burden
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
18,870
18,870
0
0
0
0
Annual Time Burden (Hours)
2,520
2,520
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$132,832
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov
Common Form ICR:
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:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(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;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
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.
Certification Date:
02/08/2017
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