Information Collection

SSA-5072 -- Annual Submission

IC 181616 under ICR 201701-0960-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form SSA-5072 SSA-5072 -- Annual Submission Form
SSA-5072 Request for Medical Treatment in SSA Facility: Patient S SSA-5072 (revised).pdf Form
SSA-5072 (current).pdf SSA-5072 (current) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SSA-5072 -- Annual Submission	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 (revised).pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.