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: 2900-0856	ICR Reference No: 202010-2900-011
Status: Historical Active	Previous ICR Reference No: 201507-2900-007
Agency/Subagency: VA	Agency Tracking No: VBA-INS-NK
Title: Authorization to Disclose Information to a Third Party (Insurance) (VA Form 29-0975)
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: 04/01/2021
	Date Received in OIRA: 02/09/2021
Terms of Clearance: In the next revision, extension, or reinstatement request for this collection, VA shall add a citation to its Title 38 authority to pledge confidentiality (see 5 CFR 1320.8(b)(3)(v)).

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2024	36 Months From Approved
Responses	1,200	0	0
Time Burden (Hours)	100	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	1,200	0	1,200
Annual Time Burden (Hours)	100	100	0
Annual Cost Burden (Dollars)	0	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: There is a small increase due to an increase in use of this form.

Annual Cost to Federal Government: $6,630

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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