Medical Report with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child

Forms and Documents

Document Name	Status
Form SSA-4814-F5 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection Form and Instruction	Modified
Form SSA-4815-F6 Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection Form and Instruction	Modified
Justification for the Non-Substantive Changes - 0500.docx Justification for No Material/Nonsubstantive Change	2017-02-07

IC Document Collections

IC ID	Document Title	Status
9396	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection Form and Instruction	Modified
187514	Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection Form and Instruction	Modified

ICR Details

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
	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

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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.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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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

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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

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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:

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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

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Common Form ICR:  No

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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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