View Information Collection (IC)

View Information Collection (IC)

IC Title:	VA Form 10-10EZR	Agency IC Tracking Number:	2900-0091

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 58.12

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10EZR	Health Benefits Update Form	VA Form 10-10EZR.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	10-10EZR	Health Benefits Update Form	VA Form 10-10EZR_PACT Act - Section 103_updates_Jan 2024.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 24VA19 Patient Medical Record - VA	FR Citation: 78 FR 17778

Number of Respondents: 859,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

	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	859,000	0	0	0	0	859,000
Annual IC Time Burden (Hours)	386,550	0	42,950	0	0	343,600
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.