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:
0960-0289
ICR Reference No:
202407-0960-005
Status:
Active
Previous ICR Reference No:
202111-0960-001
Agency/Subagency:
SSA
Agency Tracking No:
Title:
Claimant's Medications
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
07/24/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
12/13/2024
Terms of Clearance:
Prior to triannual renewal, the agency should evaluate this information collection to determine if it can be transmitted, completed, and submitted electronically, such as through Upload Document or a successor online platform. If the agency is unable to achieve this, it should include in its renewal package to OMB a letter, addressed to the OIRA Administrator and signed by a Deputy Commissioner, providing a fact-specific explanation for why this information collection cannot be made electronic at this time.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
07/31/2028
36 Months From Approved
07/31/2025
Responses
300,000
0
190,000
Time Burden (Hours)
145,900
0
74,100
Cost Burden (Dollars)
0
0
0
Abstract:
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 judge 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 judge 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.
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 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:
89 FR 74351
09/12/2024
30-day Notice:
Federal Register Citation:
Citation Date:
89 FR 97155
12/02/2024
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 Medication - PDF/Paper Version
HA-4632
Claimant's Medications
Claimant's Medications - ERE Internet Version
HA-4632
Claimant's Medications
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
190,000
0
0
110,000
0
Annual Time Burden (Hours)
145,900
74,100
0
0
71,800
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 2021, the burden was 47,500 hours. However, we are currently reporting a burden of 100,000 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 (to include the estimated Learning Costs for this information collection). These figures represent current Management Information data. * Note: The total burden reflected in ROCIS is 145,900, while the burden cited in #12 of the Supporting Statement is 100,000. 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 burden. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.
Annual Cost to Federal Government:
$316,763
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:
12/13/2024
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