2900-0768 Justification(v2)

Joint Application for Comprehensive Assistance

and Support Services for Family Caregivers

VA Form 10-10CG
OMB 2900-0768

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

Public Law (P.L.) 111-163, Caregivers and Veterans Omnibus Health Services Act of 2010 amended title 38 United States Code Chapter 17 by adding a new section, 1720G, “Assistance and Support Services for Caregivers”. Section 1720G requires the Department of Veterans Affairs (VA) to develop a Program of Comprehensive Assistance for Family Caregivers and Support Services. Under the law, primary family caregivers may be eligible to receive a stipend, access to health care coverage, mental health counseling, comprehensive caregiver education and training and expanded respite services. Caregivers may also be eligible for travel benefits when they accompany the Veteran for care or attending training. In order to administer these benefits to caregivers, it is necessary that the VA receive information about the nature of benefit being sought and the persons who will be serving as caregivers and receiving benefits.

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

The information collected will be used to determine if an Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veteran or active duty service member undergoing medical discharge qualifies for Caregiver Support Services and whether the individuals designated to serve as a primary or secondary family caregiver meet VA’s criteria to serve in these roles.

The form is completed by the Veteran, active duty service member undergoing medical discharge, caregiver, persons having power of attorney or legal guardianship as described in 38 C.F.R. § 17.32, Informed Consent and Advance Health Care Planning. The form can be mailed, completed online, or hand carried to the VA. Individuals completing the form will certify that the information is correct and true to the best of their knowledge and belief.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also described any consideration of using information technology to reduce burden.

The online Application for Comprehensive Assistance for Family Caregivers Program fillable and fileable form with instructions can be accessed at.http://www.va.gov/vaforms/medical/pdf/10-10CG.pdf

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

VA Form 10-10EZ, Application for Heath Benefits and VA Form 10-10EZR, Health Benefits Renewal Form, under OMB Approval number 2900-0091 is used as VA’s information collection for Veterans. The process for determining eligibility for Comprehensive Assistance for Family Caregivers and Support Services is initially based upon Veteran’s eligibility. To avoid duplication of information collection, VA will only require the Veteran’s and Servicemember’s information to be obtained via VA Form 10-10EZ or updated information via VA Form 10-10EZR. The 10-10EZ Form will be submitted along with the Caregiver Joint Application form to determine Veterans’ and Caregivers’ eligibility. VA has cross-walked the Caregiver Joint Application form with the existing 10-10EZ or the 10-10EZR and reduced the amount of information requested on the Caregiver Joint Application, thereby removing duplicative data collection.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

This information collection will not have any impact on small businesses or other small entities.

6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

VA's failure to collect this information would mean:

a. Veterans and their primary and secondary family Caregivers would not be allowed to apply for this benefit as authorized by Public Law (P.L.) 111-163, Caregivers and Veterans Omnibus Health Services Act of 2010, specifically, title 1, section 101 through 104.

b. The failure to apply for and receive these benefits would result in: a). negatively affecting financial resources for the Caregiver; b). reducing the quality of life and care for the Veteran; and c). potentially limiting the health care options for Caregivers.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

There are no such special circumstances.

8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The notice of Proposed Information Collection Activity was published in the Federal Register on June 14, 2011, pages 34812-34813. There were no comments received in response to this notice.

b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.

As part of the planning for the Caregivers program, the VA performed focus groups with Veterans and Caregivers (OMB Control Number 2900-0755). The VA will perform periodic reviews, through focus groups, to assess the Caregivers application process for its ease of use and other customer factors.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment or gift is provided to respondents.

10. Describe any assurance of privacy to the extent permitted by law provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

Assurances of privacy are contained in 38 U.S.C. 5701 and 7332. Respondents are informed that the information collected will become part of the Consolidated Health Record which complies with the Privacy Act of 1974. This is part of the system of records identified as 24VA19 “Patient Medical Record – VA,” “Enrollment and Eligibility Records --VA” (147VA16), and “Health Administration Center Civilian Health and Medical program Records--VA” (54VA17) as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/.

11. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

The only potentially sensitive information requested on the form is respondent’s gender. We do not believe this information would have adverse effect on any individual’s mental or physical health if revealed to him or her.

12. Estimate of the hour burden of the collection of information:

The number of respondents is estimated at 5,000 annually. The time estimate to complete the form is 15 minutes. The annual hour burden is estimated at 1,250 hours.

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.

This request covers one form, VA Form 10-10CG, Application for Comprehensive Assistance for Family Caregivers Program

c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14 of the OMB 83-I.

The cost to the respondents for completing these forms is estimated at $18,750 (1,250 hours x $15 per hour. The per hour rate is based on the Bureau of Labor Standards). We do not require any additional recordkeeping.

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

a. There is no capital, start-up, operation or maintenance costs.

b. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.

c. There are no anticipated capital start-up cost components or requests to provide information.

14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

The cost to the Federal Government is estimated at $52,000.

Administrative review by Caregiver Support Coordinator

GS12/5 @ $42/hr x 15 min x 5,000 applications / 60

$ 52,000

Note: The per hour rate of a GS 12/5 is based on the Los Angeles 2011 hourly rate table.

15. Explain the reason for any burden hour changes since the last submission.

There is no change in burden.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

There are no plans to publish the results of the information collected.

17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

VA seeks to minimize its cost to itself of collecting, processing and using the information by not displaying the expiration date.

18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

There are no exceptions.

B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS

No statistical methods are used in this data collection.

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