MEDICAL REPORT ON ADULT/CHILD WITH ALLEGATION OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION

ICR 199305-0960-001

OMB: 0960-0503

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0960-0503 199305-0960-001
Historical Active 199209-0960-010
SSA
MEDICAL REPORT ON ADULT/CHILD WITH ALLEGATION OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION
Revision of a currently approved collection   No
Regular
Approved without change 06/18/1993
Retrieve Notice of Action (NOA) 05/19/1993
  Inventory as of this Action Requested Previously Approved
06/30/1996 06/30/1996 11/30/1994
32,500 0 32,500
5,417 0 5,416
0 0 0

THE INFORMATION COLLECTED BY THESE FORMS WILL BE USED BY THE SOCIAL SECURITY ADMINISTRATION (SSA) TO DETERMINE IF AN INDIVIDUAL CLAIMING T HAVE HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION MEETS THE REQUIREMEN FOR PRESUMPTIVE DISABILITY BENEFITS. THE AFFECTED PUBLIC IS COMPRISED OF TREATING PHYSICIANS.

None
None


No

1
IC Title Form No. Form Name
MEDICAL REPORT ON ADULT/CHILD WITH ALLEGATION OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION SSA-4814, 4815

  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 32,500 32,500 0 0 0 0
Annual Time Burden (Hours) 5,417 5,416 0 0 1 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/19/1993


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