Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0500 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-4814-F5 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection Form and Instruction
SSA-4814-F5 Privacy Act Statement (revised).doc Other-Revised Privacy Act Statement
SSA-4814-F5 Medical Report on Adult with Allegation of Human Immunod SSA-4814-F5 (revised).pdf Form and Instruction
SSA-4814 (current).pdf Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection - Current IC Document

Information Collection (IC) Details

IC Title:	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	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 416.933-416.934

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-4814-F5	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	SSA-4814-F5 (revised).pdf		Yes	No	Fillable Printable
Other-Revised Privacy Act Statement			SSA-4814-F5 Privacy Act Statement (revised).doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,600	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	9,600	-9,150	18,750
Annual IC Time Burden (Hours)	1,280	-1,220	2,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection - Current	SSA-4814 (current).pdf	05/09/2019

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