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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:
2900-0001
ICR Reference No:
201312-2900-025
Status:
Historical Inactive
Previous ICR Reference No:
201204-2900-006
Agency/Subagency:
VA
Agency Tracking No:
2900-0001 VBA-COMP-NK
Title:
Veteran's Application for Compensation and or Pension (21-526), Veteran's Supplemental Claim Application (21-526b), Authorization to Disclose Information to the Department of Veterans Affairs(21-4142)
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Withdrawn and continue
Conclusion Date:
03/12/2014
Retrieve Notice of Action (NOA)
Date Received in OIRA:
02/28/2014
Terms of Clearance:
Terms of the previous clearance remain in effect. VA has requested withdrawal of this information collection request.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
03/31/2016
36 Months From Approved
03/31/2016
Responses
595,000
0
595,000
Time Burden (Hours)
441,982
0
441,982
Cost Burden (Dollars)
0
0
0
Abstract:
VA Forms 21-526 and 21-526b are used to gather the necessary information to determine a veteran's eligibility, dependency, and income, as applicable, for the compensation and/or pension benefit sought. Without this information, determination of entitlement would not be possible. VA Form 21-4142, is used to authorize the disclosure of information to the Department of Veterans Affairs (VA). VA Form 21-4142a, is used to gather private provider information from the claimant to the VA. This information collection is associated with the AO81 Rule.
Authorizing Statute(s):
US Code:
38 USC Section 5101(a)
Name of Law: Claims and forms
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
2900-AO81
Proposed rulemaking
78 FR 211
10/31/2013
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
79 FR 2
01/03/2014
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Veteran's Application for Compensation and/ or Pension(21-526), Supplemental Application for Compensation(21-526b), Authorization to Disclose Information to the Department of Veterans Affairs(21-4142)
VA Form 21-4142, VA Form 21-526, VA Form 21-526b, VA Form 21-4142a
Authorization to Disclose Information to the Department of Veterans Affairs (VA)
,
Veterans Application for Compensation and/or Pension
,
Supplemental Application for Compensation
,
General Release for Medical Provider Information To the Department of Veterans Affairs (VA)
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Burden increased because we added a new form. VA has newly created the VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA). The new VA Form 21-4142a is created to gather PHP information from the claimant and is filled out in conjunction with the VA Form 21-4142 as this form does not require a signature. It is solely used by VA to gather information to be used to develop for private medical records.
Annual Cost to Federal Government:
$12,700,356
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
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)?
Yes
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Crystal Rennie 202 632-7492 crystal.rennie@va.gov
Common Form ICR:
No
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:
02/28/2014
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