Information Collection

SSA-5072 -- Bi-Annual Submission

IC 181617 under ICR 200708-0960-008 · OMB 0960-0772.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0772 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5072 SSA-5072 -- Bi-Annual Submission	Form
SSA-5072 Request for Medical Treatment in SSA Facility: Patient S SSA-5072.pdf	Form

IC Title:

SSA-5072 -- Bi-Annual Submission

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-5072	Request for Medical Treatment in SSA Facility: Patient Self-Administered or Staff-Administered	SSA-5072.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 75

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.