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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 9396 under ICR 202306-0960-004 · OMB 0960-0500.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Other-Revised PA & PRA Statements
Other-Revised PA & PRA Statements
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 416.933-416.934

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction SSA-4814 Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection SSA-4814 (revised).pdf Yes No Fillable Printable
Other-Revised PA & PRA Statements SSA-4814 - Revised PA & PRA Statements.pdf Yes No Fillable Printable

Income Security General Retirement and Disability

 

1,307 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved 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 1,307 0 0 0 0 1,307
Annual IC Time Burden (Hours) 588 0 0 0 0 588
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SSA-4814 - Current SSA-4814 (current).pdf 06/26/2023
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.