Joint Application for Comprehensive Assistance and Support Services for Family Caregivers, VA Form 10-10CG

Forms and Documents

Document Name	Status
Form VA Form 10-10CG Application for Comprehensive Assistance for Family Caregivers Program Form and Instruction	New
Joint Application for Comprehensive Assistance and Support Services for Family Caregivers.docx Supporting Statement A	2011-05-03

IC Document Collections

IC ID	Document Title	Status
197562	Application for Comprehensive Assistance for Family Caregivers Program Form and Instruction	New

ICR Details

OMB Control No: 2900-0768	ICR Reference No: 201105-2900-003
Status: Historical Active	Previous ICR Reference No: 201105-2900-001
Agency/Subagency: VA	Agency Tracking No:
Title: Joint Application for Comprehensive Assistance and Support Services for Family Caregivers, VA Form 10-10CG
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/05/2011
	Date Received in OIRA: 05/05/2011
Terms of Clearance: VA is developing an online application. When then the online application is ready, VA will upload screen shots along with a request for a non-substantive change.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2011	6 Months From Approved
Responses	5,000	0	0
Time Burden (Hours)	1,250	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This form collects information from applicants for the Caregivers Program.

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Authorizing Statute(s): PL: Pub.L. 111 - 163 1720G Name of Law: Caregivers and Veterans Omnibus Health Services Act of 2010
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 163 1720G Name of Law: Caregivers and Veterans Omnibus Health Services Act of 2010

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AN94	Final or interim final rulemaking	76 FR 87	05/05/2011

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Application for Comprehensive Assistance for Family Caregivers Program	VA Form 10-10CG	Application for Comprehensive Assistance for Family Caregivers Program

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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	5,000	0	5,000	0	0	0
Annual Time Burden (Hours)	1,250	0	1,250	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: This is a new collection. All burden hours are considered an increase.

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Annual Cost to Federal Government: $52,000

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]? 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

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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: 05/03/2011

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