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OMB Control No: 0960-0722	ICR Reference No: 202605-0960-001
Status: Received in OIRA	Previous ICR Reference No: 202011-0960-003
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Evidence from Doctor or Hospital
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 05/27/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2026
Responses	603,108	528,000
Time Burden (Hours)	150,778	132,000
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	603,108	528,000	75,108
Annual Time Burden (Hours)	150,778	132,000	18,778
Annual Cost Burden (Dollars)	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 2023, the burden was 132,000 hours. We are currently reporting a burden of 150,778 hours. This change stems from an increase in the total number of respondents from 24,000 to 27,414. There is no change in the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. The figures represent current Management Information data for the number of responses.

Annual Cost to Federal Government: $323,860

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

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