Request for Medical Treatment in an SSA Facility: Self-Administered or Staff Administered Care

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 can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
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All Historical Document Collections

202007-0960-005	Revision of a currently approved collection	2020-10-07
201701-0960-004 Approved without change	Revision of a currently approved collection	2017-04-28
201401-0960-003 Approved without change	Revision of a currently approved collection	2014-04-30
201012-0960-002 Approved without change	Revision of a currently approved collection	2011-03-31
200708-0960-008 Approved without change	Existing collection in use without an OMB Control Number	2008-02-18

OMB Details

SSA-5072 -- Annual Submission

Federal Enterprise Architecture: Health - Health Care Services

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.