Supporting Statement--SSA-5072

Supporting Statement for the SSA-5072

Request for Medical Treatment in an SSA Employee Health Facility:

Patient Self-Administered or Staff Administered Care

OMB No. 0960-NEW

1. Justification

1. 5 USC 7901 of the United States Code allows for the establishment of contracted health service programs within governmental agencies. In 1965, the Bureau of Budget Circular A-72 formerly established the policy that all Executive Branch agencies could establish preventative health services programs for their employees. State Nurse Practice Acts govern the practice and licensure of Registered Nurses. A state’s Nurse Practice Acts set out the scope, responsibilities and limitations of nursing practice in that state. Although the scope of nursing may vary from state to state, all states require nurses to act under the supervision of a physician when performing certain duties, such as the administration of prescription medications. When the physician is not present, the Nurse Practice Acts require the nurse to follow the physician’s written orders in the administration of treatments and medications. The Nurse Practice Acts for states in which the Social Security Administration (SSA) has Employee Health Units (EHUs) is listed in the Addendum (attached).

2. SSA has 16 EHUs that provide on-site health care for employees in buildings where more than 300 employees are co-located, and of those 16 only 3 are fully owned and operated by SSA (the remainders are operated by Federal Occupational Health (FOH) and utilize FOH forms instead of SSA forms). The EHUs provide emergency care, treatment of on-the-job illnesses and injuries as well as health care for employees with chronic medical conditions and allergies requiring the administration of allergy antigen. SSA also permits employees to use the EHU for self-administration of medical treatments for a chronic health condition. When providing health care to employees with chronic medical conditions, the nurses must follow the employee’s personal physician’s order and receive approval of SSA’s Medical Director. An employee who wants to use the EHU for personal medical treatment must receive approval from the SSA Medical Director. The SSA Medical Director is responsible for the utilization of the EHU, and must ensure that all activities performed in SSA EHUs can be done safely without increased risk to the patient, the nursing staff or SSA buildings and equipment. The EHU facility must be suitable for performing the medical treatment. The risk inherent in the medical treatment must not outweigh the SSA EHU’s capacity to respond to an emergency that may arise from the treatment. The information gathered on the SSA-5072 permits the SSA Medical Director to make an informed decision regarding the appropriate utilization of the EHU and ensure that the EHU is a suitable environment for the specific medical treatment. While the main use for these forms is in the EHU’s immunotherapy program, the form is also used for other long-term medical treatments. Therefore, if an employee wishes to use the EHU for a long-term medical treatment, he/she must have his/her physician complete form SSA-5072. This form collects medical information on the nature, severity of the illness, the type, frequency and duration of the treatment, potential adverse reactions from the treatment/medication, (if medication is to be administered) the mode of administration, and recommendations pertinent to administration of the treatment or medication. The employee may bring the completed SSA-5072 to the EHU or it may be sent directly to the SSA Medical Director. The SSA-5072 is used to provide the nurse with the required written physician’s order specific to the patient for whom it is written. Respondents are physicians of SSA employees who need to have medical treatment in the SSA Employee Health Unit.

3. Form SSA-5072 is available on the Intranet as a PDF which can be downloaded and printed but is not transmitted electronically nor completed in electronic format. The form is completed and signed by the employee’s personal physician and brought to the Medical Office for review by the Medical Director. Since a wet signature is required for this form, we do not collect the information in an electronic format. Also, due to the low volume of respondents, SSA does not anticipate creating an electronic version of this form at this time.

4. The data collected is medical information pertinent to a specific individual. Thus, the nature of the information is such that it is not available elsewhere or through another means.

5. Some of the respondents may be self-employed physicians who have their own practices, or may be part of a small practice. To reduce the burden on these physicians, the form requests specific limited information, and only that which is necessary in keeping with safe medical practices.

6. If this information was not collected, SSA could not offer its employees the benefit of personal medical treatment and medication administration in its EHUs. Thus, employees would be required to take more sick leave to visit their doctor or allergist two or three times per week. Other employees would be required to either stay home form work to self-treat or find a less suitable, unhygienic place within the building to do self-treatment. SSA Productivity would be adversely affected. To maintain quality care, meet the established standards of care, and minimize liability, the information collected must, of necessity, be current and with the frequency noted – every 6 -12 months depending on the treatment/medication administration and whenever the parameters of a treatment change. Therefore, it cannot be collected less frequently. There are no technical or legal obstacles that prevent burden reduction.

7. If a participating employee’s medical condition, treatment or medication order changes, the form must be completed with updated information. This could, but is not likely to be, monthly.

8. The 60-day advance Federal Register Notice was published on September 20, 2007 at 72 FR 53803, and SSA has received no public comments. The second Notice was published on January 7, 2008, at 73 FR 1253. There have been no outside consultations with members of the public.

9. SSA provides no payment or gifts to the respondents.

10. The information provided on this form is protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130. In addition principles of medical confidentiality found in the Health Information Portability and American Health Insurance Portability and Accountability Act of 1996 (HIPAA) are also followed.

11. Form SSA-5072 collects medical information regarding an employee’s request to have personal medical treatment in the SSA EHU. This information is the basis for the employee’s request and for the Medical Director’s decision making regarding the applicant’s eligibility for using the EHU for personal medical treatment/medication administration. Without this information the SSA EHU could not honor the applicant’s request.

12. Approximately 100 employees request medication administration or personal medical treatment annually. Each differs in how often their medication dosage changes requiring a new form to be completed. Therefore, it is estimated that 25 respondents will respond once annually and 75 must provide a completed form every six months for a total of 175 responses. It is estimated to take 5 minutes for a physician to complete SSA-5072 for a total annual burden of approximately 15 hours annually. The chart below shows the burden as explained above:

Medication Dosage Changes	Number of Respondents	Frequency of Response	Number of Responses	Average Burden Per Response	Estimated Annual Burden
Annually	25	1	25	5 minutes	2.08 hours
Bi-Annually	75	2	150	5 minutes	12.5 hours
Totals	100		175		15 hours

The total burden is reflected as burden hours and no separate cost burden has been calculated.

13. There is no known cost to the respondents.

14. The annual cost to the Federal Government is approximately $780. This cost is limited to the printing of the forms. No additional staff time is required because it is performed along with other tasks involved in the review process and it saves staff from more extensive efforts to collect the necessary information.

15. This is an existing collection in use without OMB approval that will increase the public reporting burden.

16. The results of the information collected will not be published.

17. OMB has granted SSA an exemption from the requirement that the expiration date for OMB approval be printed on its forms. SSA produces millions of public-use forms, many of which have a life cycle longer that that of an OMB clearance. SSA does not periodically revise and reprint its public-use forms (e.g. on an annual basis). This exemption was granted so that otherwise useable editions of forms would not be taken out of circulation because the expiration date had been reached. In addition, government waste has been avoided because stocks of forms will not have to be destroyed and reprinted.

18. SSA is not requesting an exception to the certification requirement at CFR 1320.0 and related provisions at 5CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical methods

Statistical Methods are not used for this information collection.