Request for Medical Treatment in an SSA Employee Health Facility: Patient Self-Administered or Staff Administered Care

Forms and Documents

Document Name	Status
Form SSA-5072 SSA-5072 -- Bi-Annual Submission Form	Modified
Form SSA-5072 SSA-5072 -- Annual Submission Form	Modified
Supporting Statement 0960-0772.docx Supporting Statement A	2014-04-29
Addendum to the Supporting Statement 0960-0772.doc Supplementary Document	2014-03-06

IC Document Collections

IC ID	Document Title	Status
181617	SSA-5072 -- Bi-Annual Submission Form	Modified
181616	SSA-5072 -- Annual Submission Form	Modified

ICR Details

OMB Control No: 0960-0772	ICR Reference No: 201401-0960-003
Status: Historical Active	Previous ICR Reference No: 201012-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Medical Treatment in an SSA Employee Health Facility: Patient Self-Administered or Staff Administered Care
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: 06/16/2014
	Date Received in OIRA: 04/30/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	36 Months From Approved	06/30/2014
Responses	175	0	175
Time Burden (Hours)	15	0	15
Cost Burden (Dollars)	0	0	0

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Abstract: SSA's Employee Health Clinic (EHC) provides emergency care, treatment of on-the-job illnesses and injuries, and health care for employees with chronic medical conditions and allergies who require allergy antigens. SSA also permits employees to use the EHC for self-administration of medical treatments for a chronic health condition. SSA collects information on Form SSA-5072 to approve or deny requests for medical treatment in an SSA EHC. The respondents are the private physicians of the SSA employees seeking medical treatment in an SSA EHC.

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Authorizing Statute(s): US Code: 5 USC 7901 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:
	79 FR 7736	02/10/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 22752	04/23/2014
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
SSA-5072 -- Annual Submission	SSA-5072	Request for Medical Treatment in SSA Facility: Patient Self-Administered or Staff-Administered
SSA-5072 -- Bi-Annual Submission	SSA-5072	Request for Medical Treatment in SSA Facility: Patient Self-Administered or Staff-Administered

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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	175	175	0	0	0	0
Annual Time Burden (Hours)	15	15	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: $780

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: 04/30/2014

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