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

OMB 0960-0500

SSA uses Forms SSA-4814-F5 and SSA-4815-F6 to collect the information necessary to determine if an individual with human immunodeficiency virus (HIV) infection, who is applying for SSI disability payments, meets the requirements for PD. The respondents are the medical sources of the applicants for SSI disability payments.

The latest form for Medical Report with Allegation of Human Immunodeficiency Virus (HIV) Infection--Adult and Child expires 2022-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
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
Form SSA-4815 Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection Form and Instruction
Form SSA-4815 Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection Form and Instruction
Supporting Statement - 0500 (Final).docx Supporting Statement A
Supporting Statement - 0500 (Final).docx Supporting Statement A
0960-0500 Justification for a Non-Substantive Change.docx Justification for No Material/Nonsubstantive Change
0960-0500 Justification for a Non-Substantive Change.docx Justification for No Material/Nonsubstantive Change
Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection Form and Instruction
Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection Form and Instruction
Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection Form and Instruction
Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection Form and Instruction

All Historical Document Collections

202306-0960-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2023-06-30
202204-0960-008 Approved without change	Revision of a currently approved collection	2022-09-02
201903-0960-009 Approved with change	Revision of a currently approved collection	2019-07-22
201701-0960-014 Approved without change	No material or nonsubstantive change to a currently approved collection	2017-02-08
201604-0960-003 Approved without change	Revision of a currently approved collection	2016-06-24
201502-0960-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2015-02-05
201406-0960-008 Approved without change	Revision of a currently approved collection	2014-11-03
201109-0960-009 Approved with change	Revision of a currently approved collection	2012-01-26
200809-0960-003 Approved without change	Revision of a currently approved collection	2009-02-05
200512-0960-009 Approved without change	Extension without change of a currently approved collection	2005-12-21
200211-0960-003 Approved without change	Extension without change of a currently approved collection	2002-11-18
199906-0960-013 Approved without change	Revision of a currently approved collection	1999-06-28
199605-0960-009 Approved without change	Reinstatement with change of a previously approved collection	1996-05-28
199108-0960-001 Approved without change	New collection (Request for a new OMB Control Number)	1991-08-30

OMB Details

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

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form SSA-4814-F5

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

Fillable Printable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.