Physician's Report - SSA-3193

Medical Permit Parking Application

Documents and Forms

Document Name Document Type
Revised PRA Statement - SSA-3193.pdf Other-Revised PRA Statement
SSA-3193 Physician's Report SSA-3193 - Revised.pdf Form and Instruction
SSA-3193 - Current.pdf SSA-3193 - Current IC Document

Information Collection (IC) Details

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 - Revised.pdf		Yes	No	Fillable Fileable
Other-Revised PRA Statement			Revised PRA Statement - SSA-3193.pdf		Yes	No	Fillable Fileable

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 %

	Requested	Previously Approved
Annual Number of Responses for this IC	465	465
Annual IC Time Burden (Hours)	698	698
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-3193 - Current	SSA-3193 - Current.pdf	11/04/2020

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