Information Collection

SSA-5072 -- Bi-Annual Submission

IC 181617 under ICR 202007-0960-005 · OMB 0960-0772.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5072 Request for Medical Treatment in an SSA Facility: Self-Administered or Staff-Administered SSA-5072 -- Bi-Annual Submission	Form
SSA-5072 - Revised PA and PRA Statements.pdf	Other-Revised Privacy Act and PRA St
SSA-5072 - Revised PA and PRA Statements.pdf	Other-Revised Privacy Act and PRA St
SSA-5072 Request for Medical Treatment in an SSA Facility: Self-A SSA-5072 - Revised Version.pdf	Form
SSA-5072 Request for Medical Treatment in an SSA Facility: Self-A SSA-5072 - Revised Version.pdf	Form
SSA-5072 - Current Version.pdf Current SSA-5072	IC Document
SSA-5072 - Current Version.pdf Current SSA-5072	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-5072				No		Paper Only
Other-Revised Privacy Act and PRA Statement					No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 75

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-5072		10/07/2020

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

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