View Information Collection (IC)

View Information Collection (IC)

IC Title:	Preliminary Independent Living (IL) Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 21.50 38 CFR 21.160 38 CFR 21.162

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 28-0791	Preliminary Independent Living (IL) Assessment	28-0791(1-15).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 28-8739a	Protection of Privacy Information Statement	28-8739a.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 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	2,500	0	0	0	0	2,500
Annual IC Time Burden (Hours)	2,500	0	0	0	0	2,500
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.