Written Confirmation of Request for Accommodation; Authorization for Limited Release of Medical Information

Forms and Documents

Document Name	Status
Form VA Form 0857A Written Confirmation of Request for Accommodation; Authorization for Limited Release of Medical Information Form	New
0857a justification.doc Supporting Statement A	2010-07-13
0857 EEO comments.tif Supplementary Document	2010-04-20

IC Document Collections

IC ID	Document Title	Status
192637	Written Confirmation of Request for Accommodation; Authorization for Limited Release of Medical Information Form	New

ICR Details

OMB Control No: 2900-0767	ICR Reference No: 201004-2900-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Written Confirmation of Request for Accommodation; Authorization for Limited Release of Medical Information
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/21/2011
	Date Received in OIRA: 07/13/2010
Terms of Clearance: Approved; VA shall seek and must receive a valid OMB control number for collections of information subject to the Paperwork Reduction Act.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2014	36 Months From Approved
Responses	35	0	0
Time Burden (Hours)	18	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Reasonable accommodation for applicants will be used to assess whether requesters may qualify for an accommodation during the application or interview process.

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Authorizing Statute(s): PL: Pub.L. 110 - 325 1 Name of Law: ADA Amendments Act of 2008
   PL: Pub.L. 93 - 112 Sections, 501 and 505 Name of Law: The Rehabilitation Act of 1973
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 27	02/10/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 74	04/19/2010
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Written Confirmation of Request for Accommodation; Authorization for Limited Release of Medical Information	VA Form 0857A, VA Form 0857d	Written Confirmation of Request for Accommodation ,   Authorization for Limited Release of Medical Information

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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	35	0	0	35	0	0
Annual Time Burden (Hours)	18	0	0	18	0	0
Annual Cost Burden (Dollars)	0	0	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: This is a new data collection.

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Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 07/13/2010

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