Information Collection

SSA-4814 - Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection

IC 9396 under ICR 202603-0960-007 · OMB 0960-0500.

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 SSA-4814 - Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection	Form and Instruction
SSA-4814 Medical Report on Adult with Allegation of Human Immunod SSA-4814.pdf	Form and Instruction

IC Title:

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			www.ssa.gov	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: 816

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
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	816	-491	1,307
Annual IC Time Burden (Hours)	218	-370	588
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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].