Request for Medical Treatment in an SSA Facility: Self-Administered or Staff Administered Care

Forms and Documents

Document Name	Status
Addendum - 0772.docx Supplementary Document	2020-10-07
Supporting Statement - 0772.docx Supporting Statement A	2020-10-07

IC Document Collections

IC ID	Document Title	Status
181617	SSA-5072 -- Bi-Annual Submission Other-Revised Privacy Act and PRA Statement	Modified
181616	SSA-5072 -- Annual Submission Other-Revised Privacy Act and PRA Statements	Modified

ICR Details

OMB Control No: 0960-0772	ICR Reference No: 202007-0960-005
Status: Received in OIRA	Previous ICR Reference No: 201701-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Medical Treatment in an SSA Facility: Self-Administered or Staff Administered Care
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/07/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2021
Responses	175	175
Time Burden (Hours)	15	15
Cost Burden (Dollars)	0	0

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Abstract: SSA's Employee Health Clinic (EHC) provides emergency care, treatment of on-the-job illnesses and injuries, and health care for employees with chronic medical conditions and allergies who require allergy antigens. SSA also permits employees to use the EHC for self-administration of medical treatments for a chronic health condition. SSA collects information on Form SSA-5072 to approve or deny requests for medical treatment in an SSA EHC. The respondents are the private physicians of the SSA employees seeking medical treatment in an SSA EHC.

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Authorizing Statute(s): US Code: 5 USC 7901 Name of Law: Social Security Act
  

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:
	85 FR 45723	07/29/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 60509	09/25/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
SSA-5072 -- Bi-Annual Submission	SSA-5072	Request for Medical Treatment in an SSA Facility: Self-Administered or Staff-Administered
SSA-5072 -- Annual Submission	SSA-5072	Request for Medical Treatment in an SSA Facility: Self-Administered or Staff-Administered

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ICR Summary of Burden

	Total Request	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	175	175	0	0	0	0
Annual Time Burden (Hours)	15	15	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: $1,879

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

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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: 10/07/2020

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