2900-0188 justification (CR 7 28 14) (2)

SUPPORTING STATEMENT FOR

VA Forms 10-0103, 10-1394, 10-2421, 10-2520, 10-2914, and Form Letter 10-90

(2900-0188)

A. JUSTIFICATION

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

The Department of Veterans Affairs (VA), through its Veterans Health Administration (VHA), administers medical services established by law. Title 38 U.S.C. Section 1701(6) includes prosthetic items within the scope of medical services. Title 38 U.S.C. Section 3901, 3902, 3903, 3904, and 1162 authorize the Secretary to provide each person eligible for an automobile grant the adaptive equipment deemed necessary to insure that the person will be able to operate the automobile safely, in a manner consistent with the safety of others and to satisfy the applicable standards of licensure established by the state of residency.

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 following forms and letters are used to determine eligibility, prescribe, and authorize prosthetic devices.

VA Form 10-0103, Veterans Application for Assistance in Acquiring Home Improvement and Structural Alterations (HISA) grants, is used by the Prosthetic Service to determine eligibility/entitlement and payment of individual claims for home improvement and structural alterations. Assistance is in the form of a total lifetime benefit grant of $2000 for non-service-connected disabilities or $6800 for service-connected disabilities. The veteran applies to the local VAMC for assistance, providing a signed copy of the bid and plans and specifications with the application form.  The local HISA committee evaluates the application and bid and then approves or denies the application.  If VA Form 10-0103 was not available, the veteran cannot submit the information and documentation required to adjudicate claims for adaptations to living quarters necessitated by the veteran’s disability.

VA Form 10-1394, Application for Adaptive Equipment Motor Vehicle.  This form is used to determine eligibility/entitlement and reimbursement of individual claims for automotive adaptive equipment.  The veteran usually gets Form 10-1394 from the VAMC Prosthetics Service together with counseling regarding what they may be eligible to receive.  The veteran uses Form 10-1394 to apply for adaptive equipment on their motor vehicle.  The vehicle may be new or currently in their possession.  There is no total dollar limit on the modifications, though individual reimbursements may have associated caps.  There could be two forms for a single vehicle, as in the case where one form covers the procurement of the vehicle and a second covers modifications to the vehicle.  If VA Form 10-1394 is not provided, the veteran cannot submit the information and documentation, thus their claim for reimbursement cannot be adjudicated.

VA Form 10-2421PC, Prosthetic Authorization for Items or Services, is used for the direct procurement of new prosthetic appliances and/or services by PSAS (Prosthetic and Sensory Aids Service. PSAS personnel are authorized for open market and Federal Supply Schedule purchases, and decentralized and local beneficiary service contracts.  The purchasing authority is limited to specific items (i.e., wheelchairs, artificial limbs, eyeglasses, orthopedic devices, durable medical equipment, medical supplies, and items on local beneficiary service contracts) and only for items required by individual beneficiaries. The form is prepared and approved by the in each individual case whenever a written purchase order is necessary. It is not open ended and may be used only to obtain the prosthetic appliance or service. VA Form 10-2421PC standardizes the direct procurement authorization process, eliminates the need for separate purchase orders, expedites patient treatment and improves the delivery of prosthetic services.  Without this form the delivery time for prosthetic appliances and services would be drastically increased.

VA Form 10-2520, Prosthetic Service Card Invoice is used by the vendor as an invoice and billing document. The original and one copy of the form are forwarded to the VAMC indicated on the Prosthetic Service Card. This information is reviewed and forwarded to Fiscal Service for payment. VA Form 10-2520 standardizes repair/treatment invoices for prosthetic services rendered and standardizes the verification of these invoices.  The veteran certifies that the repairs were necessary and satisfactory.  This form is furnished to vendors upon request.

VA Form 10-2914, Prescription and Authorization for Fee Basis Eyeglasses, is used as a combination prescription, authorization and invoice. It purchases eyeglasses directly for veterans. The form is processed following receipt of eyeglasses prescriptions by the prosthetic activity.  When direct or contract purchase is determined, the form is forwarded to the vendor for filling. When the station receives eyeglasses, they are sent to the eye clinic for prescription validation. If VA Form 10-2914 is not used, the provisions of providing eyeglasses to eligible veterans may be delayed.

Form Letter 10-90, Request to Submit Quotation, is used by the VAMC Prosthetics Service to request a quotation for items listed. At the VAMC, the Prosthetics Service fills out Part 1 of the form. The correspondence package in VistA automatically generates the form. The form is faxed or mailed to the vendor, who fills out the prices and total quote. The vendor returns the completed form to the VAMC for processing. The VAMC reviews the quote on the form to complete a purchase order. This form is only used if there is a need for a quote. It is not used for the in-house manufacturing of appliances. Without this form, VA would have no standardized formal means of requesting estimates.

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.

Management officials verified that all the information sought on these forms and letters is essential.  Although all of these forms and letters (VA Forms 10-0103, 10-1394, 10-2421, 10-2520, 10-2914, and Form Letter 10-90) are internally electronic, VHA investigated the possibility of re-engineering these public-use data collections to utilize electronic submission.  The form letters are available for electronic fill-in and mail submission at http://www.va.gov/vaforms/. Although VA Form automation is not involved, the VA will accept billing from private providers submitted on any local billing form, UB (Uniform Billing) 92, or mailed and signed submission of an electronic form.

The remaining forms (VA Forms 10-0103, 10-1394, 10-2421, 10-2520, 10-2914) would have a low return on investment as a result of low transaction frequency and would not pay for their conversion within five years. Additionally, the Prosthetics and Sensory Aids Group has concerns over the need for an explanation of the benefits to which a veteran is entitled. There are further Prosthetics concerns regarding fraud and abuse (collusion of the veteran and vendor). There appears to be no reasonably cost-effective combination of technologies and management control that can minimize the risk of significant harm inherent in placing these on the Internet.

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.

Since these forms are for specific individuals and require personal input, duplication is not anticipated.  This information is not available from an alternate source.

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

Although small businesses are impacted by this data collection, the burden is reduced to an absolute minimum by utilization of these forms and letters.  Additionally, to decrease the burden on the respondent, VA will accept billing from private providers, submitted on any local billing or Uniform Billing Form.

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.

The frequency of use of these forms and letters is determined by the medical requirements of the individual veterans. We would not be responsive to the needs of our veteran population if these forms and letters were used less frequently.

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 special circumstances. The collection is conducted in a manner consistent with guidelines in 5 C.F.R. 1320.6

8a. 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 July 3, 2014, page 45206. We received no comments 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.

Consultations have not been held outside VA beyond the 60- and 30-day Federal Register notices. The information solicited is considered standard within the industry and is the absolute minimum necessary. There have been no reports of vendors or beneficiaries having difficulty in completing the forms or form letters.

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

No payment has been authorized for respondents.

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

Respondents are informed that the information collected will become part of the Consolidated Health Record that complies with the Privacy Act of 1974.  These forms are part of the system of records identified as 24VA136 “Patient Medical Record – VA” as set forth in the Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html.

11.    Provide additional justification for any questions of a sensitive nature, 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.

There are no questions of a sensitive nature.

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

a. What is the total annual burden?

The total annual burden of this collection is estimated at 5,738 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.

2900-0188	Respondents	Frequency	Responses Annually	Min.	Divided by 60	Annual Burden Hours
10-0103	7,000	1	7,000	5	60	583
10-1394	4,000	1	4,000	15	60	1,000
10-2421	1,000	1	1,000	4	60	67
10-2520	700	1	700	4	60	47
10-2914	50,000	1	50,000	4	60	3,333
FL 10-90	8500	1	8,500	5	60	708
			71,200			5,738

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.

The annual cost to the respondents is $137,712 (5,738 x $24.00).

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 is no an anticipated capital start-up cost component 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 total cost to the Federal Government is approximately $167,113.00.

(a) Cost for VA Form 10-0103 is $16,064

Mail cost (700 x $0.41) = $ 287

6,300 faxed to vendor x [$22.92/hr (GS 7/5)/60mins] x 1 min/form = $2,407

7,000 clerical reviews x [$22.92/hr (GS 7/5)/60mins] x 5 mins/form = $13,370

(b) Cost for VA Form 10-1394 is $12,841.

Mail cost (200 x $0.41) = $ 82

3,800 faxed to vendor x [$22.92/hr (GS 7/5)/60mins] x 1 min/form = $1,452

4,000 professional reviews x [$33.92/hr (GS 11/5)/60mins] x 5 mins/form = $11,307

(c) Cost for VA Form 10-2421 is $2,295.

Mail cost (250 x $0.41) = $ 98

750 faxed to vendor x [$22.92/hr (GS 7/5)/60mins] x 1 min/form = $287

1,000 clerical reviews x [$22.92/hr (GS 7/5)/60mins] x 5 mins/form =$1,910

(d) Cost for VA Form 10-2520 is $1,607.

Mail cost (70 x $0.41) = $ 29

630 faxed to vendor x [$22.92/hr (GS 7/5)/60mins] x 1 min/form = $ 241

700 clerical reviews x [$22.92/hr (GS 7/5)/60mins] x 5 mins/form = $ 1,337

(e) Cost for VA Form 10-2914 is $114,740

Mail cost (5,000 x $0.41) = $ 2,050

45,000 faxed to vendor x [$22.92/hr (GS 7/5)/60mins] x 1 min/form = $13,883

50,000 clerical reviews x [$22.92/hr (GS 7/5)/60mins] x 5 mins/form = $77,125

(f) Cost for FL 10-90 is $19,506.

Mail cost (850 x $0.41) = $ 349

7,650 faxed x [$22.92/hr (GS 7/5)/60mins] x 1 min/form = $ 2,922

8,500 clerical reviews x [$22.92/hr (GS 7/5)/60mins] x 5 mins/form = $16,235

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

There are no changes to report for the burden hours.

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 information collected on any of the forms.

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

A valid expiration date will be added to the form.

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 such exceptions.

B. Collection of Information employing Statistical Methods

This collection of information does not employ statistical methods.

9