Supporting Statement - 0624

Supporting Statement for Forms SSA-3192, SSA-3193, and SSA-3194

Medical Permit Parking Application Forms

41 cfr 102-71.20 and 102-74.305

omb No. 0960-0624

1. Justification

1. Introduction/Authoring Laws and Regulations

As per section 41 CFR 102-71.20 and 102-74.305 of the Code of Federal Regulations, Social Security Administration (SSA) employees and contractors with qualifying medical conditions who park at SSA-owned and -leased facilities may apply for an SSA medical parking permit.

2. Description of Collection

SSA uses three forms for the medical permit parking program: (1) SSA-3192, the Application and Statement, which an individual completes when first applying for the medical parking space; (2) SSA-3193, the Physician’s Report, which the applicant’s physician completes to verify the medical condition; and (3) SSA-3194, Renewal Certification, which medical parking permit holders complete 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, the burden below is only for SSA contractors and physicians (of both SSA employees and contractors).

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.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently

If SSA did not collect this information, we would be unable to assign medical parking permits for qualifying SSA employees or contractors, which would violate the regulations cited in #1 above. Since we only collect this information when an employee or 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.

7. Special Circumstances

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

8. Solicitation of Public Comment and Other consultations with the Public

SSA published the 60-day advance Federal Register Notice on May 23, 2014, at 79 FR 29834, and we received no public comments. We published the 30-day Federal Register Notice on August 28, 2014, at 79 FR 51387. 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.

9. Payment or Gifts to Respondents

SSA provides no payment or gifts to the respondents.

10. 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.

11. Justification for Sensitive Questions

The respondents for these forms must provide medical information one could consider as 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.

12. Estimates of Public Reporting Burden

Below is the annual reporting burden for these forms. Note: this burden is for contractors and physicians only, since SSA employees are PRA-exempt.

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Annual Burden (hours)
SSA-3192	290	1	30	145
SSA-3193	580	1	90	870
SSA-3194	93	1	5	8
Totals	963			1,023

The total burden represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents

There is no known cost burden to the respondents.

14. Annual Cost to the Federal Government

The annual cost to the Federal Government for conducting this collection is approximately $93,453.20. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

Processing NOTE: The agency maintains a contract with Spectrum Healthcare Resources Incorporated to have a Public Health Services physician process and evaluate these forms in addition to the federal Government employees; this contract dollar amount is not included in the annual cost above.

15. Program Changes or Adjustments to the Information Collection Request

The change in burden hours stems from an increase of respondents for Forms SSA-3192 and SSA-3193. In addition, we show a decrease of respondents for Form SSA-3194. Finally, both the SSA-3192 and SSA-3193 take longer for the public to complete than the SSA‑3194, which increases the total annual burden for this collection substantially.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. 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.

18. 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.