View Information Collection Request (ICR) Package
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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:
2900-0629
ICR Reference No:
201105-2900-005
Status:
Historical Active
Previous ICR Reference No:
200801-2900-009
Agency/Subagency:
VA
Agency Tracking No:
2900-0629
Title:
Application for Extended Care Services
Type of Information Collection:
Extension without change of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
12/20/2011
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/27/2011
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
12/31/2014
36 Months From Approved
12/31/2011
Responses
6,000
0
6,000
Time Burden (Hours)
9,000
0
9,000
Cost Burden (Dollars)
0
0
0
Abstract:
Collects information to establish eligibility for extended care benefits, establishes financial liability veteran to pay if accepted for placement in Extended Care Services, and establishes veteran has agreed to make any applicable copayment.
Authorizing Statute(s):
US Code:
38 USC 1722A
Name of Law: Determination of inability to defray necessary expenses;
US Code:
38 USC 1729
Name of Law: Recovery by the United States of the cost of certain
US Code:
38 USC 1705
Name of Law: Management of health care: patient enrollment system
US Code:
38 USC 1710B
Name of Law: Eligibility for hospital, nursing home, and domiciliary
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
76 FR 96
05/18/2011
30-day Notice:
Federal Register Citation:
Citation Date:
76 FR 141
07/22/2011
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
Application for Extended Care Services
10-10EC
Application for Extended Care Benefits
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
6,000
6,000
0
0
0
0
Annual Time Burden (Hours)
9,000
9,000
0
0
0
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:
Annual Cost to Federal Government:
$121,750
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)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Denise McLamb 202-565-8374 denise.mclamb@mail.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:
07/27/2011
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