Veteran's Application for C&P, Veteran's Supplemental Claim Application, General Release for Med Provider Info to the Dept of VA, Authorization and Consent to Release Info to the Dept of VA

Forms and Documents

Document Name	Status
Form VA Form 21-526 Veteran's Application for Compensation and/ or Pension; Authorization and Consent to Release Information to the DVA, Veteran's Supplemental Claim Application Form	Modified
Suppl Stmt - DOMA, 21-526, 21-526b (non-sub).docx Supplementary Document	2014-06-19
21-4142a Supplemental Stmt (2-25-14).docx Supplementary Document	2014-03-14
21-4142 Supplemental Stmt (2-25-14).docx Supplementary Document	2014-03-14
2900-0001 -SuppStmt (6-19-14) OIRA.docx Supporting Statement A	2014-06-19

IC Document Collections

IC ID	Document Title	Status
28062	Veteran's Application for Compensation and/ or Pension; Authorization and Consent to Release Information to the DVA, Veteran's Supplemental Claim Application Form	Modified

ICR Details

OMB Control No: 2900-0001	ICR Reference No: 201403-2900-010
Status: Historical Active	Previous ICR Reference No: 201204-2900-006
Agency/Subagency: VA	Agency Tracking No: 2900-0001 VBA-COMP-NK
Title: Veteran's Application for C&P, Veteran's Supplemental Claim Application, General Release for Med Provider Info to the Dept of VA, Authorization and Consent to Release Info to the Dept of VA
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/20/2014
	Date Received in OIRA: 03/21/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	36 Months From Approved	03/31/2016
Responses	724,108	0	595,000
Time Burden (Hours)	452,740	0	441,982
Cost Burden (Dollars)	0	0	0

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Abstract: VA Forms 21-526 and 21-526b are used to gather the necessary information to determine a veteran's eligibility, dependency, and income, as applicable, for the compensation and/or pension benefit sought. Without this information, determination of entitlement would not be possible. VA Form 21-4142, is used to authorize the disclosure of information to the Department of Veterans Affairs (VA). VA Form 21-4142a, is used to gather private provider information from the claimant to the VA.

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Authorizing Statute(s): US Code: 38 USC Section 5101(a) Name of Law: Claims and forms
  

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:
	79 FR 2	01/03/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 54	03/20/2014
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
Veteran's Application for Compensation and/ or Pension; Authorization and Consent to Release Information to the DVA, Veteran's Supplemental Claim Application	VA Form 21-526, VA Form 21-4142, VA Form 21-4142a, VA Form 21-526b	Veteran's Application For Compensation and/or Pension ,   Authorization to Disclose Information to the Department of Veterans Affairs (VA) ,   General Release for Medical Provider Information to the Department of Veterans Affairs (VA) ,   Veteran's Supplemental Claim for Compensation

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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	724,108	595,000	0	129,108	0	0
Annual Time Burden (Hours)	452,740	441,982	0	10,758	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: Burden increased because VA's Compensation Service added a new form to the icr 2900-0001. VA has newly created the VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA). The new VA Form 21-4142a is created to gather Private Health Provider information from the claimant and is filled out in conjunction with the VA Form 21-4142 as this form does not require a signature. It is solely used by VA to gather information to be used to develop for private medical records.

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Annual Cost to Federal Government: $12,700,356

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:  Yes

Description/Changes for Common Form Usage: 

Approved RCFs using this ICR

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

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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: 03/21/2014

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