Addendum to the Supporting Statement for 0960-0624

Addendum to the 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

Minor Revisions to the Collection Instruments

We are updating contact information and minor rewording to improve clarity to all three forms. We are also updating the American with Disabilities Act Statements. General changes are as follows:

• Change #1: We are changing the title of Deputy Director to Director throughout Form SSA-3192, Form SSA-3193 and Form SSA-3194.

Justification #1: The position of Deputy Director does not exist under the new organizational structure of the Office of Protective Security Services.

• Change #2: We are changing the statement of “and the ADA Amendments Act of 2008.” to “section 501(g) of the Rehabilitation Act of 1973, as amended, 29 U.S.C. 791(g).,” throughout Forms SSA-3192, SSA-3193, and SSA-3194.

Justification #2: This simplifies the reference to the Act.

Specific changes to the individual forms are as follows:

Changes to the SSA-3192, Application and Statement:

• Change #1: First page, first paragraph following the heading INSTRUCTIONS: Adding text at the end of first sentence to read: “…section 501(g) of the Rehabilitation Act of 1973, as amended, 29 U.S.C. 791(g).”

Justification #1: We are adding this language for clarification of the law pertaining to these instructions.

• Change #2: Second sentence of that paragraph, bolding and italicizing the word substantially. Replacing the word “restricts” with the word “limits”

• Justification #2: SSA is revising the language to improve clarity, consistency, and readability.

• Change #3: First page, second paragraph:

• Adjusted order of submission to read as: “directly forward…via a separate fax/facsimile to the Director, Office of Protective Security Services at (410)-597-0455 or sealed envelope….”

• Changed title from Deputy Director to Director. The Deputy position is no longer in the organizational structure.

• Justification #3: SSA is revising the language to improve clarity, consistency, and readability; we changed the title as the position of Deputy Director does not exist under the new organizational structure of the Office of Protective Security Services (as mentioned above).

• Change #4: First page, HIPAA Statement paragraph, revising last paragraph contact information to read as: “…Medical Parking Office at (410) 966-8814.”

• Justification #4: SSA is revising the language to ensure we show the correct information.

• Change #5: 1^st paragraph after the Privacy Act Statement, bolding and underlining the statement: “However, failure to provide…”

• Justification #5: SSA is revising the language to improve clarity, consistency, and readability.

• Change #6: Second Page of form, Item number 1 spelled out initial.

• Justification #6: SSA is revising the language to improve clarity, consistency, and readability.

• Change #7: Second Page of form, Item number 5 adding request for Entrance number and provided example.

• Justification #7: SSA is adding language to improve clarity and readability.

• Change #8: Second Page of form, moved text box with the statement “Your physician must also submit form….may prohibit the agency from processing your request.” to above the Applicant’s Authorization and Certification.

• Justification #8: SSA is revising the language to improve clarity and readability.

• Change #9: Updating contact name on second page, last paragraph of form to read: “…Medical Parking Office at (410) 966-8814.”

• Justification #9: SSA is revising the language to ensure we show the correct information.

• Change #10: Second Page of form, paragraph adjacent to heading Applicant’s Authorization and Certification; changing text to read: “…authorized SSA officials, including the Director, Office of Protective Security Services….”

• Justification #10: SSA is revising the language to improve clarity, consistency, and readability.

• Change #11: Second Page of form, under signature line:

  • Adding the bolded heading, “SUBMISSION INSTRUCTIONS.”

  • Changing addressee of the P.O. Box from Deputy Director to Director.

• Justification #11: SSA is revising the language to improve clarity, consistency, and readability; we changed the title as the position of Deputy Director does not exist under the new organizational structure of the Office of Protective Security Services (as mentioned above).

Changes to the SSA-3193, Physician’s Report:

• Change #1: First Page of form, Item number 1 spelled out initial.

Justification #1: SSA is revising the language to improve clarity, consistency, and readability

• Change #2: First Page of form, paragraph adjacent to heading Applicant’s Authorization to Release Medical Documentation; changing text to read: “…authorized SSA officials, including the Director, Office of Protective Security Services….”

Justification #2: SSA is revising the language to improve clarity, consistency, and readability. We changed the title as the position of Deputy Director does not exist under the new organizational structure of the Office of Protective Security Services (as mentioned above).

• Change #3: 1^st paragraph after the Privacy Act Statement, bolding and underlining the statement: “However, failure to provide…”

• Justification #3: SSA is revising the language to improve clarity and readability.

• Change #4: Under the heading Section B – To Be Completed By The Physician, INSTRUCTIONS we are making the following revisions:

• Adding the following text: “…section 501(g) of the Rehabilitation Act of 1973, as amended, 29 U.S.C. 791(g).”

• Removing the word severely in parentheses the text should read as: “…or mental impairment that substantially limits…”

• Bolding and italicizing the word substantially.

• Bolding and underlining the “two most recent” clinical notes, in the second paragraph of this section.

Justification #4: We are adding this language for clarification of the law pertaining to these instructions. SSA is revising the language to improve clarity, consistency, and readability.

• Change #5: We made the following revisions to the second page of form:

• Moved text box with the statement “Medical Documentation required with this form to the top of the form under the first two paragraphs. Also changed the language to read as “Required Medical Documentation With This Form,” in all capital letters.

• Item number 1, we spelled out initial.

• Under Item number 10, we are adding certification statement and check box for the physician.

Justification #5: SSA is revising the language to improve clarity, consistency, and readability.

• Change #6: Second Page of form, under telephone/signature line:

• Adding the bolded heading, “SUBMISSION INSTRUCTIONS.”

• Changing address of the P.O. Box from Deputy Director to Director.

• Updating contact name to read: “…Medical Parking Office at (410) 966-8814.”

Justification #6: SSA is revising the language to improve clarity and consistency. We changed the title as the position of Deputy Director does not exist under the new organizational structure of the Office of Protective Security Services (as mentioned above), and revising the telephone language to ensure we show the correct information.

Changes to the SSA-3194, Renewal Certification

• Change #1: On the first page, first paragraph, we made the following revisions under the INSTRUCTIONS heading:

• Revised the language following the heading “To be completed by individual possessing a medical parking assignment,” bolding the word INSTRUCTIONS.

• Adding text at the end of first sentence to read: “…section 501(g) of the Rehabilitation Act of 1973, as amended, 29 U.S.C. 791(g).”

• Adding text of the third sentence to read: “…please complete the below certification and return it to the Director, office of Protective Security Services, by fax to (410) 597-0455 or bring to the servicing Parking and credentialing office with your expiring permit.”

Justification #1: SSA is revising the language to improve clarity, consistency, and readability. We are adding this language for clarification of the law pertaining to these instructions. We changed the title as the position of Deputy Director does not exist under the new organizational structure of the Office of Protective Security Services (as mentioned above), and revising the telephone language to ensure we show the correct information.

• Change #2: We are updating the contact name of the last sentence, first paragraph of form to read: “…questions…Medical Parking Office at (410) 966-8814.”

Justification #2: We are revising the telephone language to ensure we show the correct information.

• Change #3: On the first Page of form, we are spelling out the initial in Item #1.

Justification #3: SSA is revising the language to improve clarity, consistency, and readability.

• Change #4: We made the following revisions to the first Page of form, in the paragraph adjacent to heading Renewal Certification;

• Changing text to read: “…promptly inform the Direction, Office of Protective Security Services…”

• Changing text to read: “…if I leave…promptly return this permit to the servicing Parking and Credentialing Office.”

Justification #4: SSA is revising the language to improve clarity, consistency, and readability, and we changed the title as the position of Deputy Director does not exist under the new organizational structure of the Office of Protective Security Services (as mentioned above).

• Change #5: Second page 1^st paragraph after the Privacy Act Statement, bolding and underlining the statement: “However, failure to provide…”

Justification #5: SSA is revising the language to improve clarity, consistency, and readability.

We will make the above revisions upon OMB's approval of this information collection request. We do not anticipate any changes to the burden for this collection based on the above minor language revisions.