Information Collection

Physician's Report - SSA-3193

IC 186165 under ICR 202007-0960-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3193 Physician's Report Physician's Report - SSA-3193	Form and Instruction
Revised PRA Statement - SSA-3193.pdf	Other-Revised PRA Statement
Revised PRA Statement - SSA-3193.pdf	Other-Revised PRA Statement
SSA-3193 Physician's Report SSA-3193 - Revised.pdf	Form and Instruction
SSA-3193 Physician's Report SSA-3193 - Revised (Signable).pdf	Form and Instruction
SSA-3193 - Current.pdf SSA-3193 - Current	IC Document
SSA-3193 - Current.pdf SSA-3193 - Current	IC Document

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3193				Yes	Yes	Fillable Fileable
Other-Revised PRA Statement					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 %

table that charts list of burden
	Approved	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

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3193 - Current		11/04/2020

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].