Information Collection

Physician's Report - SSA-3193

IC 186165 under ICR 201706-0960-005 · OMB 0960-0624.

⚠️ Notice: This information collection may be referencing outdated material.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 - SSA-3193 Form and Instruction
SSA-3193 Physician's Report SSA-3193 (2017) Mock-up.pdf Form and Instruction
ssa3193(current).pdf Current SSA-3193 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Physician's Report - SSA-3193	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 41 CFR 102-71.20 41 CFR 102-74.305 (To search for a specific CFR, visit the Code of Federal Regulations.)

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	SSA-3193 (2017) Mock-up.pdf		No		Paper Only

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 465	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	465	-115	580
Annual IC Time Burden (Hours)	698	-172	870
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-3193	ssa3193(current).pdf	07/19/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.