Information Collection

Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult

IC 9396 under ICR 200809-0960-003 · OMB 0960-0500.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0500 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4814-F5 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult	Form and Instruction
SSA-4814-F5 Medical Report on Adult with Allegation of Human Immunod Medical Report on Adult SSA-4814-F5.pdf	Form and Instruction

IC Title:

Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.933-416.934

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 and Instruction	SSA-4814-F5	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Medical Report on Adult SSA-4814-F5.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 46,200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	46,200	-12,900	59,100
Annual IC Time Burden (Hours)	7,700	-2,150	9,850
Annual IC Cost Burden (Dollars)	0	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.