Information Collection

SSA-3193 (Physician)

IC 186166 under ICR 202606-0960-011 · OMB 0960-0624.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3193 (Physicia Renewal Certification SSA-3193 (Physician)	Form and Instruction
Privacy Act Statement - Revised.docx	Other-Revised PA Statement
SSA-3193 (Physicia Renewal Certification SSA 3193 -Revised.pdf	Form and Instruction
SSA 3193 - Current.pdf SSA-3193 (Physician) - Current	IC Document

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: 41 CFR 102-74.305 41 CFR 102-71.20 (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 (Physician)				Yes	No	Fillable Fileable
Other-Revised PA Statement					Yes	No	Fillable Fileable

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 233

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 85 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	233	302	-151	82
Annual IC Time Burden (Hours)	350	686	-343	7
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3193 (Physician) - Current		07/29/2026

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

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