Physician's Report

Medical Permit Parking Application

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0624 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-3193 Physician's Report Form and Instruction
SSA-3193 Physician's Report Form SSA-3193.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Physician's Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 41 CFR 101.20-104.2

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3193	Physician's Report	Form SSA-3193.pdf		No		Paper Only

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	400	219	181
Annual IC Time Burden (Hours)	600	487	113
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.