Medical Report on Adult with Allegation of Human Immune Deficiency Virus Infection and Medical Report on Child with Allegation of Human Immune Deficiency Virus Infection
ICR 199906-0960-013
OMB: 0960-0500
Federal Form Document
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0960-0500 can be found here:
Medical Report on Adult with
Allegation of Human Immune Deficiency Virus Infection and Medical
Report on Child with Allegation of Human Immune Deficiency Virus
Infection
Collection is
approved consistent with changes in 10/22/99 fax.
Inventory as of this Action
Requested
Previously Approved
01/31/2003
01/31/2003
11/30/1999
59,100
0
32,500
9,850
0
5,417
0
0
0
SSA uses the forms to obtain
information from a medical source concerning an individual who has
filed for SSI disability benefits with an allegation of HIV
infection. The information is necessary for SSA field office
personnel to determine whether the individual meets the
requirements for a presumptive disability payment. The respondents
are medical sources of individuals who apply for SSI disability
benefits.
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.