View Information Collection Request (ICR) Package

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: 2900-0858	ICR Reference No: 201709-2900-024
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-DJ
Title: Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142a and 21-4142)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/05/2018
	Date Received in OIRA: 11/16/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2021	36 Months From Approved
Responses	132,400	0	0
Time Burden (Hours)	11,033	0	0
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	132,400	132,400
Annual Time Burden (Hours)	11,033	11,033
Annual Cost Burden (Dollars)	0	0

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: This is a request for a new control number. VA Forms 21-4142 and 21-4142a were previously approved under control number 2900-0001. They have been separated from this control group so a new control number can be assigned.

Annual Cost to Federal Government: $7,169,467

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

Agency Contact: Cynthia Harvey - Pryor 202 461-5870 cynthia.harvey-pryor@va.gov

Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.