View Information Collection Request (ICR) Package
Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
This script is used to control the display of information in this page.
Display additional information by clicking on the following:
All
Brief and OIRA conclusion
Abstract/Justification
Legal Statutes
Rulemaking
FR Notices/Comments
IC List
Burden
Misc.
Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
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:
0960-0292
ICR Reference No:
202105-0960-009
Status:
Active
Previous ICR Reference No:
201801-0960-004
Agency/Subagency:
SSA
Agency Tracking No:
Title:
Claimant's Recent Medical Treatment
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
11/19/2024
Retrieve Notice of Action (NOA)
Date Received in OIRA:
06/30/2021
Terms of Clearance:
In accordance with 5 CFR 1320, this information collection is approved.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
11/30/2026
36 Months From Approved
11/30/2024
Responses
300,000
0
200,000
Time Burden (Hours)
195,900
0
33,333
Cost Burden (Dollars)
0
0
0
Abstract:
When DDSs deny a claim at the reconsideration level, the claimant has a right to request a hearing before an administrative law judge (ALJ). For the hearing, SSA asks the claimant to complete and return the HA-4631 if the claimant’s file does not reflect a current, complete medical history as the claimant proceeds through the appeals process. ALJs must obtain the information to update and complete the record and to verify the accuracy of the information. Through this process, ALJs can ascertain whether the claimant’s situation changed. The ALJs and hearing office staff use the response to make arrangements for consultative examination(s) and the attendance of any expert witnesses, if appropriate. During the hearing, the ALJ offers any completed questionnaires as exhibits and may use them to: (1) Refresh the claimant’s memory, and (2) shape their questions. The respondents are claimants requesting hearings on entitlement to Old Age Survivors and Disability Insurance benefits or SSI payments.
Authorizing Statute(s):
US Code:
42 USC 423
Name of Law: Social Security Act
US Code:
42 USC 405
Name of Law: Social Security Act
US Code:
42 USC 1382c
Name of Law: Social Security Act
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:
86 FR 17874
04/06/2021
30-day Notice:
Federal Register Citation:
Citation Date:
86 FR 33007
06/23/2021
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
Claimant's Recent Medical Treatment
HA-4631
Claimant's Recent Medical Treatment
Electronic Records Express Submission
HA-4631
Claimant's Recent Medical Treatment
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
300,000
200,000
0
0
100,000
0
Annual Time Burden (Hours)
195,900
33,333
0
0
162,567
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:
When we last cleared this IC in 2017, the burden was 33,333 hours. However, we are currently reporting a burden of 150,000 hours. This change stems an increase in the number of responses from 200,000 to 300,000 combined with a change in the amount of burden time for response. These figures represent current Management Information data. * Note: The total burden reflected in ROCIS is 195,900, while the burden cited in #12 of the Supporting Statement is 150,000. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a 30-minute, + one-way, drive burdens. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.
Annual Cost to Federal Government:
$305,060
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
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?
No
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:
06/30/2021
An official website of the United States government
The .gov means it's official.
The site is secure.
