2900-0720 (final)

Supporting Statement for:

2900-0720

VA Form 21-0773

Operation Enduring Freedom/Operation Iraqi Freedom Seriously Injured/Ill Service Member Veteran Worksheet

A. Justification

1. The Department of Veterans Affairs (VA) through its Veterans Benefits Administration (VBA), administers an integrated program of benefits and services, established by law, for veterans, service personnel, and their dependents and/or beneficiaries. Title 5 U.S.C. 552(a) provides that the term ``maintain'' includes maintain, collect, use, or disseminate. This form is used, as recommended by President Bush’s Interagency Task Force on Returning Global War on Terror (GWOT) Heroes, as a checklist for Veterans Service Representatives to verify they have given information, applications, and/or referral service to our Operation Enduring Freedom or Operation Iraqi Freedom service members who have at least six months remaining on active duty and who may have suffered a serious injury or illness. This form adheres to the Task Force recommendations to improve the timeliness, ease of application, and delivery of services and benefits to GWOT servicemembers.

2. VA Form 21-0773 is a checklist for Veterans Service Representatives to verify they have given information, applications, and/or referral service to our Operation Enduring Freedom or Operation Iraqi Freedom service members who have at least six months remaining on active duty and who may have suffered a serious injury or illness. This form will be maintained in the veteran’s claims folder.

3. VA Form 21-0773 is available on the One-VA Website in a fillable electronic format. VBA is currently hosting this form on a secure server and does not currently have the technology in place to allow for the complete submission of the form. Validation edits are performed to assure data integrity. Efforts within VA are underway to provide a mechanism to allow the information to be submitted electronically with a recognized signature technology. There currently is no utility process in place that will allow the data submitted on the form to be incorporated with an existing centralized legacy database.

4. Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency, which maintains the necessary information, nor is it available from other sources within our Department.

5. The collection of information does not involve small businesses or entities.

6. This form is designed in a “user friendly” format, incorporating plain English, to comply with the President’s Memorandum of June 1, 1998, Plain Language in Government Writing.

7. There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.

8. The Department notice was published in the Federal Register on August 29, 2014, Volume 79, No. 168, page 51653. No comments were received in response to this notice.

9. No payments or gifts to respondents have been made under this collection of information.

10. The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22/28, “Compensation, Pension, Education, and Rehabilitation Records—VA” as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

1. Number of Respondents: 14,000 per year.

2. Frequency of Response is one time for most beneficiaries.

3. Annual burden: 7,000 hours.

4. Estimated completion time: 30 minutes

5. According to the U.S. Bureau of Labor Statistics Average Hourly Earnings, the cost to the respondent is $24, making the total cost to the respondents an estimated $168,000 (7,000 burden hours x $24 per hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

1. Processing/Analyzing costs $480,900

(GS-12/5 @ $40.66 x 14,000 x 30/60 minutes = $284,620)

(GS-9/5 @ $28.04 x 14,000 x 30/60 minutes = $196,280)

2. Printing and production cost $284

3. Total cost to government $481,184

15. The reporting burden has not changed.

The form has been updated to include an expiration date placeholder.

16. The information collection is not for publication or tabulation use.

17. We are not seeking approval to omit the expiration date for OMB approval.

18. This submission does not contain any exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

The data collection does not employ statistical methods.