View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0960-0772	ICR Reference No: 202007-0960-005
Status: Historical Active	Previous ICR Reference No: 201701-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Medical Treatment in an SSA Facility: Self-Administered or Staff Administered Care
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/08/2024
	Date Received in OIRA: 10/07/2020
Terms of Clearance: Approved to facilitate agency discontinuing the collection. If they agency seeks to reinstate this collection in the future, it should respond, as appropriate, to prior passback from OMB prior to resubmission.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2027	36 Months From Approved	05/31/2024
Responses	175	0	175
Time Burden (Hours)	15	0	15
Cost Burden (Dollars)	0	0	0

Annual Cost to Federal Government: $1,879

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

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