View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 2900-0858	ICR Reference No: 202009-2900-020
Status: Historical Active	Previous ICR Reference No: 201709-2900-024
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Authorization to Disclose Information to the VA (VA Form 21-4142), General Release of Medical Provider Information to the VA (VA Form 21-4142a)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/19/2021
	Date Received in OIRA: 05/24/2021
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2024	36 Months From Approved
Responses	127,397	0	0
Time Burden (Hours)	10,616	0	0
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	127,397	-5,003	132,400
Annual Time Burden (Hours)	10,616	-417	11,033
Annual Cost Burden (Dollars)	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The respondent burden has decreased due to the estimated number of receivables averaged over the past two years.

Annual Cost to Federal Government: $3,369,091

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? No

Agency Contact: Maribel Aponte 202 266-4688 maribel.aponte@va.gov

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