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: 2900-0219	ICR Reference No: 202104-2900-006
Status: Historical Active	Previous ICR Reference No: 202102-2900-011
Agency/Subagency: VA	Agency Tracking No: 2900-0219
Title: CHAMPVA Benefits - Application, Claim, Other Health Insurance, Potential Liability & Misc Expenses
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: 10/13/2021
	Date Received in OIRA: 09/09/2021
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2024	36 Months From Approved	03/31/2021
Responses	180,142	0	177,225
Time Burden (Hours)	34,548	0	46,176
Cost Burden (Dollars)	0	0	0

Authorizing Statute(s): US Code: 38 USC Section 1781 Name of Law: Medical care for survivors and dependents of certain veterans
   US Code: 42 USC Section 2651 Name of Law: Recovery by United States
   US Code: 10 USC Section 1079 Name of Law: Contracts for medical care for spouses and children: plans
   US Code: 10 USC Section 1086 Name of Law: Contracts for health benefits for certain members, former members, and their dependents
   US Code: 42 USC Section 2652 Name of Law: Regulations
   US Code: 42 USC Section 2653 Name of Law: Limitation or repeal of other provisions for recovery of hospital and medical care costs
   EO: EO 9397 Name/Subject of EO: Number System for Federal Accounts Relating to Individual Persons
   US Code: 38 USC Section 501 Name of Law: Rules and regulations

Citations for New Statutory Requirements: None

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion	Change Due to Adjustment in Estimate
Annual Number of Responses	180,142	177,225	180,142	-177,225
Annual Time Burden (Hours)	34,548	46,176	34,548	-46,176
Annual Cost Burden (Dollars)	0	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: Changes in the burden are based on program history.

Annual Cost to Federal Government: $706,317

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: Frances O'Donnell 703 405-2449 fran.odonnell@cathexiscorp.com

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