SSA-5072 -- Bi-Annual Submission

SSA will insert the following revised Privacy Act and PRA Statements into the form as soon as
possible:
Privacy Act Statement
Collection and Use of Personal Information
Section 7901 of Title 5 of the United States Code allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from administering or allowing the self-administration of medical
treatment in a Social Security Administration Employee Health Clinic (SSA EHC).
We will use the information you provide to approve or deny requests for self or staffadministered medical treatment in an SSA EHC. We may also share the information for the
following purposes, called routine uses:
•

To the appropriate Federal, State or local agency responsible for investigation of an
accident, disease, medical condition, or injury as required by pertinent legal authority;
and

•

To the Office of Workers’ Compensation Programs in connection with a claim for
benefits filed by an employee.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0237, Employees’ Medical Records, as published in the Federal Register (FR) on
January 11, 2006, at 71 FR 1854. Additional information, and a full listing of all of our SORNs,
is available on our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget
(OMB) control number. We estimate that it will take about 5 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.