Information Collection Request

Medical Report with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child

ICR 202306-0960-004 · OMB 0960-0500 · Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0960-0500 can be found here:

Forms and Documents

Forms and supporting documents for this ICR
Document	Type	Status	Availability
Form SSA-4814 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Available
Form SSA-4814 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Repair queued
Form SSA-4815 Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Available
Form SSA-4815 Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified	Repair queued
Supporting Statement - 0500 (Final).docx	Supporting Statement A	Uploaded 2022-09-02	Available
Supporting Statement - 0500 (Final).docx	Supporting Statement A	Uploaded 2022-09-02	Repair queued
0960-0500 Justification for a Non-Substantive Change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-06-26	Available
0960-0500 Justification for a Non-Substantive Change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-06-26	Missing upstream

Information collection document groups
IC ID	Collection	Type	Status
9396	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified
9396	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified
187514	Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified
187514	Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction	Modified

Record metadata
Status	Active
Agency/Subagency	SSA
OMB Control No	0960-0500
Type of Information Collection	No material or nonsubstantive change to a currently approved collection
Previous ICR Reference No	202204-0960-008
Date Submitted to OIRA	2023-06-30
Requested Expiration Date	1969-12-31