Information Collection

Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection

IC 9396 under ICR 202306-0960-004 · OMB 0960-0500.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4814 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction
Form SSA-4814 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction
SSA-4814 - Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
SSA-4814 - Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
SSA-4814 Medical Report on Adult with Allegation of Human Immunod SSA-4814 (revised).pdf	Form and Instruction
SSA-4814 Medical Report on Adult with Allegation of Human Immunod SSA-4814 (revised).pdf	Form and Instruction
SSA-4814 (current).pdf SSA-4814 - Current	IC Document
SSA-4814 (current).pdf SSA-4814 - Current	IC Document

IC Title:

Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.933-416.934

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-4814	Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	SSA-4814 (revised).pdf		Yes	No	Fillable Printable
Other-Revised PA & PRA Statements			SSA-4814 - Revised PA & PRA Statements.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,307

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,307	1,307
Annual IC Time Burden (Hours)	588	588
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-4814 - Current	SSA-4814 (current).pdf	06/26/2023

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