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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-5072 SSA-5072 -- Bi-Annual Submission	Form	New	Repair queued
Form SSA-5072 SSA-5072 -- Annual Submission	Form	New	Repair queued
Addendum--SSA-5072.doc	Supplementary Document	Uploaded 2007-09-25	Available
Supporting Statement--SSA-5072.doc	Supporting Statement A	Uploaded 2008-01-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
181617	SSA-5072 -- Bi-Annual Submission	Form	New
181616	SSA-5072 -- Annual Submission	Form	New

ICR Details

OMB Control No: 0960-0772	ICR Reference No: 200708-0960-008
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Medical Treatment in an SSA Employee Health Facility: Patient Self-Administered or Staff Administered Care
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/01/2008
	Date Received in OIRA: 02/18/2008
Terms of Clearance: Consistent with SSA's clarification that it is not a covered entity under HIPAA, this information collection is approved. OMB appreciates SSA's diligence in addressing collections that have been existance without OMB approval.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2011	36 Months From Approved
Responses	175	0	0
Time Burden (Hours)	15	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Social Security Administration (SSA) operated Employee Health Clinics on-site in eight different states. These clinics provide health care for all SSA employees including treatments of personal medical conditions when authorized through a physician. The SSA-5072 is the employee's personal physician's order form. The information collected on the SSA-5072 gives the nurses the guidance they need by law to perform certain medical procedures and to administer prescription medications such as allergy immunotherapy. Also, the information collected by the SSA-5072 allows the SSA Medical Officer to determine whether the treatment can be administered safely and appropriately in the SSA Employee Health Units. Each state of the Union has a Nurse Practice Act governing the practice of registered nurses in the state. All Nurse Practice Acts require that registered nurses administer prescription medications and certain medical treatments by following a licensed physician's orders. Form SSA-5072 provides the vehicle for the physician to provide these orders to the SSA nursing staff.

---

Authorizing Statute(s): US Code: 5 USC 7901 Name of Law: null
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 53803	09/20/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 1253	01/07/2008
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

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

---

ICR Summary of Burden

table that charts list of burden

	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	175	0	0	175	0	0
Annual Time Burden (Hours)	15	0	0	15	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is an existing collection in use without OMB approval that will increase the public reporting burden.

---

Annual Cost to Federal Government: $780

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(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: 02/18/2008

---