Supporting Statement 0624

Supporting Statement for formS SSA-3192, SSA-3193, AND SSA-3194

Medical PERMIT Parking Application FORMS

41 cfr 101.20-104.2

omb No. 0960-0624

1. Justification

1. Introduction/Authoring Laws and Regulations - As per section 41 CFR 101.20-104.2 of the Code of Federal Regulations, Social Security Administration (SSA) employees and contractors with a qualifying medical condition who park at SSA-owned and -leased facilities are eligible to apply for an SSA medical parking permit. SSA uses three forms as part of this program: SSA-3192, the Application and Statement (the person seeking the permit completes this when they first apply for the medical parking space); SSA-3193, the Physician’s Report (the applicant’s physician completes this to verify the medical condition and also provides medical evidence that supports the diagnosis); and SSA-3194, the Renewal Certification (medical parking permit holders complete this to verify their continued need for the permit). The respondents are SSA employees and contractors seeking medical parking permits and their physicians. NOTE: Because SSA employees are Federal workers exempt from the requirements of the Paperwork Reduction Act (PRA), this Information Collection Request is only for 1) SSA contractors and 2) physicians (of both SSA employees and contractors).

2. Description of Collection - SSA uses the information provided by these forms to identify the SSA employee/contractor who wants a medical parking permit, and to determine if that employee is entitled to the permit based on their medical condition.

3. Use of Information Technology to Collect the Information - We did not create electronic versions of Forms SSA-3192, SSA-3193, SSA-3194 under the agency’s Government Paperwork Elimination Act due to their low volume of use.

4. Why We Cannot Use Duplicate Information - The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use any other collection instruments that collect similar data.

4. Minimizing Burden on Small Respondents - This collection does not affect small businesses or other small entities.

4. Consequence of Not Collecting Information or Collecting it Less Frequently - If we did not have this information collection, we would be unable to assign medical parking permits for qualifying SSA employees/contractors, which would violate the regulations cited in Question #1. Since we only collect this information when an employee/contractor initially applies for a permit or submits the required annual confirmation of need, we cannot collect it less frequently.

There are no technical or legal obstacles to burden reduction.

4. Special Circumstances - There are no special circumstances that would cause us to collect this information in a manner inconsistent with 5 CFR 1320.5.

4. Solicitation of Public Comment and Other consultations with the Public - SSA published the 60-day advance Federal Register Notice on June 30, 2011, at 76 FR 38449, and we received no public comments. We published the 30-day Federal Register Notice on September 9, 2011, at 76 FR 55999. If we receive any public comments in response to the 30-day Notice, we will forward them to OMB.

There have been no outside consultations with members of the public.

4. Payment or Gifts to Respondents - SSA provides no payment or gifts to the respondents.

4. Assurances of Confidentiality - SSA protects and holds confidential the information from this form 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.

4. Justification for Sensitive Questions - The respondents for these forms must provide medical information that one could consider sensitive. However, SSA needs this information to determine if the applicant qualifies for a medical parking permit, we do not share the information with anyone outside of the SSA contracted physician who makes the eligibility determination.

4. Estimates of Public Reporting Burden - Below is the annual reporting burden for these forms. Note that this burden is for contractors and physicians only, since SSA employees are PRA-exempt. The total burden represents burden hours, and we did not calculate a separate cost burden.

Form	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Annual Burden (hours)
SSA-3192	75	1	30	38
SSA-3193	400	1	90	600
SSA-3194	500	1	5	42
Totals	975	-	-	680

4. Annual Cost to the Respondents - There is no known cost burden to the respondents.

4. Annual Cost to the Federal Government - The annual cost to the Federal Government for conducting this collection is approximately $103,620. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

4. Program Changes or Adjustments to the Information Collection Request - There are no changes to the public reporting burden.

4. Plans for Publication Information Collection Results - SSA will not publish the results of the information collection.

4. Displaying the OMB Approval Expiration Date - OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycle exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms, (e.g., on an annual basis), OMB granted this exemption so that SSA would not have to destroy stocks of useable forms with expired OMB approval dates, thus avoiding Government waste.

4. Exception to Certification Statement - SSA is not requesting an exception to the certification requirements at 5 CFR 1320.0 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods:

SSA does not use statistical methods for this information collection.