View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	SSA-3193 (Physician)	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:

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

Federal Enterprise Architecture Business Reference Module

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 %

	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	233	0	302	-151	0	82
Annual IC Time Burden (Hours)	350	0	686	-343	0	7
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

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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