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:
2900-0736
ICR Reference No:
201903-2900-015
Status:
Historical Active
Previous ICR Reference No:
201602-2900-037
Agency/Subagency:
VA
Agency Tracking No:
VBA-COMP-NK
Title:
Authorization to Disclose Personal Information to a Third Party (VA Form 21-0845)
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:
04/24/2020
Retrieve Notice of Action (NOA)
Date Received in OIRA:
09/12/2019
Terms of Clearance:
In its next revision or extension request of this collection, VA shall: 1. Allow the respondent to request information to be shared with an organization (rather than a specific representative of an organization), or provide a legal opinion from VA OGC that such a change would be inconsistent with regulation or statute and 2. That the mailing address of the respondent is an option field.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
04/30/2022
36 Months From Approved
04/30/2020
Responses
20,000
0
20,000
Time Burden (Hours)
1,667
0
1,667
Cost Burden (Dollars)
0
0
0
Abstract:
VA Form 21-0845 is used to release information in the following circumstances: where the individual identifies the particular information and consents to its use; for the purpose for which it was collected or a consistent purpose (i.e., a purpose which the individual might have reasonably expected).
Authorizing Statute(s):
US Code:
38 USC 5701
Name of Law: Confidential nature of claims
US Code:
5 USC 552a
Name of Law: Privacy Act Law
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:
84 FR 9248
05/07/2019
30-day Notice:
Federal Register Citation:
Citation Date:
84 FR 16023
07/29/2019
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
Authorization to Disclose Personal Information to a Third Party
VA Form 21-0845
Authorization to Disclose Personal Information to a Third Party
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
20,000
20,000
0
0
0
0
Annual Time Burden (Hours)
1,667
1,667
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:
$256,788
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:
Danny Green 202 421-1354 danny.green2@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:
09/12/2019
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