OMB control number
Request for Medical Treatment in an SSA Facility: Self-Administered or Staff Administered Care
OMB 0960-0772 · SSA.
OMB 0960-0772
SSA's Employee Health Clinic (EHC) provides emergency care, treatment of on-the-job illnesses and injuries, and health care for employees with chronic medical conditions and allergies who require allergy antigens. SSA also permits employees to use the EHC for self-administration of medical treatments for a chronic health condition. SSA collects information on Form SSA-5072 to approve or deny requests for medical treatment in an SSA EHC. The respondents are the private physicians of the SSA employees seeking medical treatment in an SSA EHC.
The latest form for Request for Medical Treatment in an SSA Facility: Self-Administered or Staff Administered Care expires 2021-01-31 and is listed under ICR 201701-0960-004.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Addendum - 0772.docx | Supplementary Document |
| Supporting Statement - 0772.docx | Supporting Statement A |
 SSA-5072 -- Bi-Annual Submission |
Other-Revised Privacy Act and PRA Statement |
| SSA-5072 -- Annual Submission |
Other-Revised Privacy Act and PRA Statements |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202007-0960-005 | Revision of a currently approved collection | 2020-10-07 | ||
| 201701-0960-004 | Revision of a currently approved collection | 2017-04-28 | Approved without change | |
| 201401-0960-003 | Revision of a currently approved collection | 2014-04-30 | Approved without change | |
| 201012-0960-002 | Revision of a currently approved collection | 2011-03-31 | Approved without change | |
| 200708-0960-008 | Existing collection in use without an OMB Control Number | 2008-02-18 | Approved without change |
OMB Details
SSA-5072 -- Annual Submission
Federal Enterprise Architecture: Health - Health Care Services
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form SSA-5072 | Request for Medical Treatment in SSA Facility: Patient Self-Administered or Staff-Administered | Paper Only | Form |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.