Supporting Statement for Form SSA-5072
Request for Medical Treatment in an SSA Employee Health Facility:
Patient Self-Administered or Staff-Administered Care
OMB No. 0960-0772
Justification
Introduction/Authoring Laws and Regulations
5 USC 7901 of the United States Code allows for the establishment of contracted health service programs within governmental agencies. In 1965, the Bureau of Budget Circular A-72 formally established the policy that all Executive Branch agencies could establish preventative health services programs for their employees. State Nurse Practice Acts govern the practice and licensure of registered nurses. A state’s Nurse Practice Act sets out the scope, responsibilities, and limitations of nursing practice in that state. Although the scope of nursing may vary from state to state, all states require nurses to act under the supervision of a physician when performing certain duties, such as the administration of prescription medications. When the physician is not present, the Nurse Practice Acts require the nurse to follow the physician’s written orders in the administration of treatments and medications.
Description of Collection
The Social Security Administration (SSA) operates onsite Employee Health Clinics (EHC) in eight different States. These clinics provide health care for all SSA employees including treatment of personal medical conditions when authorized through a physician. Form SSA-5072 is the employee’s personal physician’s order form. The information we collect on Form SSA-5072 gives the nurses the guidance they need by law to perform certain medical procedures and to administer prescription medications such a as allergy immunotherapy. In addition, the form allows the medical officer to determine whether they can administer treatment safely and appropriately in the SSA EHCs. Respondents are physicians of SSA employees who need to have medical treatment in an SSA EHC.
Use of Information Technology to Collect the Information
SSA did not create an electronic version of Form SSA-5072 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 100 respondents complete the form. This is less than the GPEA cut-off of 50,000.
Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents
This collection does affect small businesses or other entities.
Consequence of Not Collecting Information or Collecting it Less Frequently If we did not use Form SSA-5072, we would not be able to offer employees the benefit of personal medical treatment and medication administration in our EHCs. Thus, employees would be required to take more sick leave to visit their doctor or allergist two or three times per week. Other employees would be required to either stay home from work to self-treat, or find a less suitable, unhygienic place within the building to do self-treatment. If a participating employee’s medical condition, treatment, or medication orders change, the employee takes the form back to the physician to have the information updated. This could, but is not likely to be, monthly. Because we collect the information annually and bi-annually, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.
Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on January 12, 2017, at 82 FR 3838, and we received no public comments. The 30-day FRN published on March 28, 2017 at 82 FR 15412. If we receive any comments in response to this Notice, we will forward them to OMB.
Payment or Gifts to Respondents
SSA does not provide payment or gifts to the respondents.
Assurances of Confidentiality
SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.
Justification for Sensitive Questions
SSA uses Form SSA-5072 to collect medical information regarding an employee’s request to have personal medical treatment in the SSA EHC. This information is the basis for the employee’s request and for the Medical Director’s decision-making regarding the applicant’s eligibility for using the EHC for personal medical treatment or medication administration. Even though we must collect potentially sensitive medical information, we take measures to secure and protect it, and only necessary personnel have access to it. Without this information, the SSA EHC would be unable to honor the applicant’s request.
Estimates of Public Reporting Burden
Modality of Collection |
Number of Respondents |
Frequency of Response |
Number of Responses |
Average Burden Per Response (minutes) |
Estimated Total Annual Burden (hours) |
SSA-5072 Annually |
25 |
1 |
25 |
5 |
2 |
SSA-5072 Bi-Annually |
75 |
2 |
150 |
5 |
13 |
Totals |
100 |
|
|
|
15 |
The total burden for this information collection request is 15 hours. This figure represents burden hours, and we did not calculate a separate cost burden.
Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden to the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $780. This estimate is a projection of the costs for printing the collection instrument.
Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirement at
5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).
B. Collections of Information Employing Statistical methods
SSA does not use statistical methods for this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement for SSA Form 5072 entitled: |
| Author | Elaine Papp |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |