SSA-5072 -- Annual Submission

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

OMB: 0960-0772

IC ID: 181616

Information Collection (IC) Details

View Information Collection (IC)

SSA-5072 -- Annual Submission
 
No Modified
 
Voluntary
 

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 (revised).pdf No   Paper Only

Health Health Care Services

 

25 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 25 0 0 0 0 25
Annual IC Time Burden (Hours) 2 0 0 0 0 2
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SSA-5072 (current) SSA-5072 (current).pdf 01/17/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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