Medical Permit Parking Application

Forms and Documents

Document Name	Status
Form SSA-3192 Application and Statement - SSA-3192 Form and Instruction	Modified
Form SSA-3194 Renewal Certification - SSA-3194 Form and Instruction	Modified
Form SSA-3193 Physician's Report - SSA-3193 Form and Instruction	Modified
Addendum - 0624.docx Supplementary Document	2017-10-11
Supporting Statement - 0624.docx Supporting Statement A	2017-10-11

IC Document Collections

IC ID	Document Title	Status
9641	Application and Statement - SSA-3192 Form and Instruction	Modified
186166	Renewal Certification - SSA-3194 Form and Instruction	Modified
186165	Physician's Report - SSA-3193 Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0624	ICR Reference No: 201706-0960-005
Status: Historical Active	Previous ICR Reference No: 201405-0960-003
Agency/Subagency: SSA	Agency Tracking No:
Title: Medical Permit Parking Application
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/13/2017
	Date Received in OIRA: 10/11/2017
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2020	36 Months From Approved	11/30/2017
Responses	937	0	963
Time Burden (Hours)	900	0	1,023
Cost Burden (Dollars)	0	0	0

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Abstract: SSA employees and contractors with a qualifying medical condition who park at SSA-owned and leased facilities may apply to receive a medical parking permit. SSA uses three forms for this program: (1) SSA-3192, the Application and Statement, which an individual completes when first applying for the medical parking space; (2) SSA-3193, the Physician's Report, which the applicant's physician completes to verify the medical condition; and (3) SSA-3194, Renewal Certification, which medical parking permit holders complete to verify their continued need for the permit. The respondents are SSA employees and contractors seeking medical parking permits and their physicians. Note: Because SSA employees are Federal workers exempt from the requirements of the Paperwork Reduction Act, the burden below is only for SSA contractors and physicians (of both SSA employees and contractors).

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Authorizing Statute(s): US Code: 40 USC 486(c) Name of Law: Management and Disposal of Government Property
   PL: Pub.L. 106 - 580 Sec. 205(c) Name of Law: The Federal Property and Administrative Services Act of 1949
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 29136	06/27/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 43066	09/13/2017
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Application and Statement - SSA-3192	SSA-3192	Application and Statement
Renewal Certification - SSA-3194	SSA-3194	Renewal Certification
Physician's Report - SSA-3193	SSA-3193	Physician's Report

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	937	963	0	0	-26	0
Annual Time Burden (Hours)	900	1,023	0	0	-123	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The change in burden hours stems from a decrease of respondents using Forms SSA-3192, SSA-3193, and SSA-3194.

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Annual Cost to Federal Government: $26,719

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? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/11/2017

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