Supporting Statement - 0772

Supporting Statement for Form SSA-5072

Request for Medical Treatment in an SSA Facility:

Self-Administered or Staff-Administered

OMB No. 0960-0772

1. Justification

1. 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 an independent licensed healthcare provider when performing certain duties, such as the administration of prescription medications. When the independent licensed healthcare provider is not present, the Nurse Practice Acts require the nurse to follow the an independent licensed healthcare provider’s written orders in the administration of treatments and medications.

2. 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 an independent licensed healthcare provider. Form SSA‑5072 is the employee’s personal independent licensed healthcare provider’s order form. The information we collect on Form SSA-5072 gives the EHC 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 information allows the medical officer to determine whether they can administer treatment safely and appropriately in the SSA EHCs. Respondents are independent licensed healthcare providers of SSA employees who need to have medical treatment in an SSA EHC.

3. Use of Information Technology to Collect the Information

This collection does not currently have a fully public-facing Internet version, as we prioritized other information collections for full electronic conversions.  As per our 4/3/20 conversation with OIRA, we welcome OIRA to join our conversations with OMB on IT Mods; however, as our IT Mod programming is an ongoing project, we cannot provide timelines for when we will be able to make any particular ICR available via the Internet.  We will convert existing ICRs to full electronic versions depending on how they fall within our overall IT Mod schema, but this unconnected to the PRA approval lifecycle.

4. 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.

5. Minimizing Burden on Small Respondents

This collection does affect small businesses or other entities.

6. 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 independent licensed healthcare provider 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.

7. 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.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on July 29, 2020, at 85 FR 45723, and we received one public comment:

• Comment: The commenter requests that SSA remain consistent in our terminology when we discuss the SSA-5072. On the form, we use the term “independent licensed healthcare providers” in place of naming specific health care providers (e.g., doctors, nurses, etc.). The commenter request that SSA use the term “independent licensed healthcare providers” in all of our documentation for this form.

• SSA Response: We understand the commenter’s request, and agree with it. While we were not able to accommodate this request in our recent publication of the 30-day comment period Notice, we have changed the terminology in our Supporting Statement to accommodate this request.

The 30-day FRN published on September 25, 2020, at 85 FR 60509. If we receive any comments in response to this Notice, we will forward them to OMB.

9. Payment or Gifts to Respondents

SSA does not provide payment or gifts to the respondents.

10. 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.

11. 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.

12. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Number of Responses	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)	Average Theoretical Hourly Cost Amount (dollars)*	Total Annual Opportunity Cost (dollars) **
SSA-5072 Annually	25	1	25	5	2	$96.85*	$194**
SSA-5072 Bi-Annually	75	2	150	5	13	$96.85*	$1,259**
Totals	100				15		$1,453**

* We based this figure on average an independent licensed healthcare provider’s hourly salary, as reported by Bureau of Labor Statistics data (https://www.bls.gov/oes/current/oes291216.htm).

** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application. There is no actual charge to respondents to complete the application.

We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection. Per our management information data, we believe that 25 minutes for annual responses and 150 minutes for bi-annual responses accurately shows the average burden per response for reading the instructions, gathering the facts, and answering the questions. Based on our current management information data, the current burden information we provided is accurate. The total burden for this collection instrument is 15 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $1,453. SSA does not charge respondents to complete our applications.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden to the respondents.

14. Annual Cost To Federal Government

The annual cost to the Federal Government is approximately $1,879. This estimate accounts for costs from the following areas:

Description of Cost Factor	Methodology for Estimating Cost	Cost in Dollars
Designing and Printing the Form	Design Cost + Printing Cost	$175
Distributing, Shipping, and Material Costs for the Form	Distribution + Shipping + Material Cost	0
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time	GS-12 employee x # of responses x processing time	$1,387
Full-Time Equivalent Costs	Out of pocket costs + Other expenses for providing this service	0
Systems Development, Updating, and Maintenance	GS employee x man hours for development, updating, maintenance	$317
Quantifiable IT Costs	Any additional IT costs	0
Total		$1,879

* We have inserted a $0 amount for cost factors that do not apply to this collection

SSA is unable to break down the costs to the Federal government further than we already have.  Because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee who completes this work (GS-12) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.

15. Program Changes or Adjustments to the Information Collection Request

There are no changes to the public reporting burden.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

17. 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.

18. 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.

5