Medical Permit Parking Application

Forms and Documents

Document Name	Status
Form SSA-3192 Application and Statement Form and Instruction	Modified
Form SSA-3194 Renewal Certification Form and Instruction	Unchanged
Form SSA-3193 Physician's Report Form and Instruction	Unchanged
Clearance Request for SSA-3192 - OMB 0960-0624.doc Justification for No Material/Nonsubstantive Change	2012-05-14

IC Document Collections

IC ID	Document Title	Status
9641	Application and Statement Form and Instruction	Modified
186166	Renewal Certification Form and Instruction	Unchanged
186165	Physician's Report Form and Instruction	Unchanged

ICR Details

OMB Control No: 0960-0624	ICR Reference No: 201205-0960-009
Status: Historical Active	Previous ICR Reference No: 201106-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Medical Permit Parking Application
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/27/2012
	Date Received in OIRA: 05/15/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2014	10/31/2014	10/31/2014
Responses	975	0	975
Time Burden (Hours)	680	0	680
Cost Burden (Dollars)	0	0	0

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Abstract: SSA employees and contractors with a qualifying medical condition who park at SSA-owned and -leased facilities may receive a medical parking permit. SSA uses three forms as part of this program: Form SSA-3192, the Application and Statement (the person seeking the permit completes this when they first apply for the medical parking space); Form SSA-3193, the Physician's Report (the applicant's physician completes this to verify the medical condition); and Form 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. This non-substantive change affects only the information collection instrument, Form SSA-3192. We are referencing the companion form (SSA-3193) by name and form number to improve clarity on the SSA-3192's instructions, thus making it easier to use for respondents. This change does not affect the burden to any of the collection instruments.

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Authorizing Statute(s): None

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:
	76 FR 38449	06/30/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 55999	09/09/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Application and Statement	SSA-3192	Application and Statement
Renewal Certification	SSA-3194	Renewal Certification
Physician's Report	SSA-3193	Physician's Report

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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	975	975	0	0	0	0
Annual Time Burden (Hours)	680	680	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: $103,620

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: 05/15/2012

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