Information Collection

Medical Source Statement of Ability to Do Work-Related Activities (Mental)

IC 188400 under ICR 201611-0960-004 · OMB 0960-0662.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0662 can be found here:

Documents and Forms

Document Name Document Type
Form HA-1152 Medical Source Statement of Ability to Do Work-Related Activities (Mental) Form
HA-1152 Medical Source Statement of Ability to Do Work-Related A HA-1152-BK - Revised Version.docx Form
HA-1152-BK - Current Version.pdf Current HA-1152 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical Source Statement of Ability to Do Work-Related Activities (Mental)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1512 20 CFR 416.912 20 CFR 404.1517 20 CFR 416.913 20 CFR 416.917 20 CFR 404.1513

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-1152	Medical Source Statement of Ability to Do Work-Related Activity (Mental)	HA-1152-BK - Revised Version.docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	150,000	150,000
Annual IC Time Burden (Hours)	37,500	37,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current HA-1152	HA-1152-BK - Current Version.pdf	11/29/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.