2900-0427_justification_111715

SUPPORTING STATEMENT FOR 2900-0427

VA FORM 10-0048, Former Prisoner of War Medical History

A. JUSTIFICATION

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

VA Form 10-0048, Former POW Medical History, is used to collect data in response to Public Law 97-37, the "Former Prisoner of War Benefits Act of 1981," that liberalizes eligibility requirements and extends the existing benefits. Additionally, the National Advisory Committee on Former Prisoners Of War requires this information for their annual submission to Congress.

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.

A VA physician will obtain the information on the VA Form 10-0048 during a medical examination. If these questions were not asked, the physician would be unable to assess the health care, disability compensation or rehabilitation needs of the Former Prisoner Of War (FPOW). The importance of collecting this very detailed information when the veteran is first seen is critical, not only with the physician evaluating the veteran but also by the rating specialist who will rate this claim. The rater also reviews the statements given by the veteran on this form not only at the first claim submission but in future years when other disabilities are claimed. Feedback from POW physicians in the field indicates their appreciation of the well thought out content and structure of the form. It is useful not only for Compensation and Pension examinations but also as a guide and reference for treatment planning for the FPOW patient. The questions in the form make it relevant for FPOWS of current as well as prior conflicts.

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.

This form is completed only by a VA Physician and is available in a fillable, savable format on the intranet at: http://vaww.va.gov/vaforms/. It can be filled out electronically or printed blank and filled out by hand. The form is not available to the public because it has been determined that a physician should be present when these sensitive issues are discussed.

4. Describe effort 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.

Similar information is not available to VA and may only be obtained from the FPOW.

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

No small businesses or other small entities are impacted by this information collection.

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.

This information is collected only once when the FPOW is first examined by the VA. This information is vital to understanding the FPOW’s experience of captivity and its medical consequences. This information is essential for both the Compensation and Pension claims process and the planning and implementation of clinical care for the FPOW veteran.

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 July 10, 2015, page 39837. 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.

Outside consultation is conducted with the public through the 60- and 30-day Federal Register notices. The Secretary of Veterans Affairs Advisory Committee on Former Prisoners of War approved this form and the current members see the results on a regular basis. A list of the current membership of the Advisory Committee members is attached.

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

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 24VA19 “Patient Medical Record – VA” 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, 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.

All material is necessary for evaluation of the veteran's physical or psychological status. Questions of a sensitive nature would be asked only if a physician determined that there was a medically justifiable reason for obtaining the information.

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

a. While the number of surviving FPOWs is decreasing because most were captured during WWII or the Korean War, there are still over 10,000 FPOWs who have not been seen by VA. Outreach at the local level by VA is ongoing. It is estimated average annual rate of new FPOW exams will be in the range of 50-75 individuals annually. This is a non-recurring document that requires approximately one and a half hours of the veteran's time to complete (in the course of a clinical interview as noted in number 2, above).

Form	Respondents	Responses	Burden	Total
10-0048	75	75	90	113
TOTAL	75	75	90	113

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 only one form.

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 annualized cost to respondents is estimated at $2,712 (113 X $24 per hour). We do not require any additional recordkeeping.

(Department of Labor statistics, http://www.bls.gov/ )

13. Provide an estimate of the total annual cost burden to respondents or record keepers 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.

75 exams X $22.92/hr (GS 7/5 clerk) x 45 min/exam	$ 1289
75 exams X $67.21/hr (GS 15/5 physician) x 2.5 hrs	$ 12,602
TOTAL	$ 13,891

15. Explain the reason for any program changes or adjustments reported in Items 13 or 14 of OMB 83-I

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.

An expiration date will be included on the forms in compliance with OMB policy.

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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