201412-2900-010_2900-0681SupportStatement_2015-08-19

Supporting Statement for

Preliminary Independent Living (IL) Assessment

OMB 2900-0681

VA Form 28-0791

A. Justification

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

Under 38 U.S.C. 3104(a)(1), 3109 and 38 CFR 21.50, 21.160, and 21.162, the Department of Veterans Affairs (VA) collects information from disabled veterans to determine the scope of their potential IL needs under the Vocational Rehabilitation and Employment program.

2. Indicate how, and 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.

This form will be used by case managers during the initial IL evaluation. During this face-to-face meeting, the case manager investigates difficulties the veteran may be experiencing in a wide range of areas such as walking, climbing stairs, moving in and out of chair, and other physical functions that may impede his or her ability to live independently. The case manager then uses this information to schedule additional assessments of capability and functioning and determines needed interventions.

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 describe any consideration of using information technology to reduce burden.

VA does not use information technology to collect this information, since open-ended questioning may be needed to obtain complete information.

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.

This information is not available from any other source. It is based upon each veteran’s perception of his/or her capabilities.

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

The collection of information will not have any impact upon 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.

The collection of this information is required by law (38 U.S.C. 3104 (a)(1) and 3109). Failure to collect this information would have a detrimental impact upon the determination of appropriate rehabilitation goals for veterans participating in the independent living program.

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 that impose any exceptional burdens on respondents.

8. 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 Department notice was published in the Federal Register on February 19, 2015, Vol. 80, No. 33. No comments were received in response to this notice.

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

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

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.

11. Information will be kept private to the extent permitted by law.

12. 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.

This form collects potentially sensitive information. Questions are included which pertain to Alcohol/Substance Abuse and Personal, Emotional, and Spiritual Needs. These questions are necessary because they address issues which can have a significant impact upon the veteran’s ability to profit from vocational rehabilitation services, and also because they may indicate areas in which therapeutic intervention is needed. Responses to questions in the aforementioned areas will only be used for the purpose of determining the ability of the veteran to profit from participation in the IL program and/or the veteran’s need for assistance. Prior to completion of this form, each veteran will have signed a Protection of Privacy Information Statement, VA Form 28-8739a.

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

Estimate of Information Collection Burden.

a.	Number of Respondents:	2,500
b.	Frequency of Response:	One-time
c.	Annual burden hours:	2,500 hours
d.	Estimated Completion Time: The estimated completion time of one hour is based upon test interviews.
e.	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 $60,000 (2,500 burden hours x $24.00 per hour).

14. 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).

This submission does not involve any recordkeeping costs.

15. 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.

Estimated Costs to the Federal Government

a.	Processing/Analyzing costs – Annual cost for processing this form [2,500 responses x 1 hour x $38.27/hour (a case manager’s average grade of GS 12/3)]:	$95,675
b.	Forms are available on the VA inter/intranet forms websites.
c. d.	Printing and production cost Total cost to government $95,675

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

There is no change in burden hours. The expiration date placeholder has been added to the form.

17. 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.

The information collection is not for publication or tabulation use.

18. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

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

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

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

B. Collection of Information Employing Statistical Methods

This collection of information does not employ statistical methods.

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