Agent Orange Registry Code Sheet

Forms and Documents

Document Name	Status
Form VA Form 10-9009 Agent Orange Registry Code Sheet Form	Modified
Registry exam privacy statement OMB Aug 17.docx Supplementary Document	2017-08-15
PIA FY15 EAS (signed).pdf Supplementary Document	2017-08-15
OMB AO Registry Justification B PDHS Registry_072617.doc Supporting Statement B	2017-08-02
OMB AO A 2900-0376 justification 121416(3).docx Supporting Statement A	2017-08-18

IC Document Collections

IC ID	Document Title	Status
28576	Agent Orange Registry Code Sheet Form	Modified

ICR Details

OMB Control No: 2900-0376	ICR Reference No: 201609-2900-003
Status: Historical Active	Previous ICR Reference No: 201211-2900-003
Agency/Subagency: VA	Agency Tracking No: 2900-0376
Title: Agent Orange Registry Code Sheet
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/25/2017
	Date Received in OIRA: 12/30/2016
Terms of Clearance: OMB approves this collection consistent with the understanding that the VA Agent Orange Registry is created for administrative purposes. If any of the collected data is ultimately used for non-administrative purposes, such as for research, then VA will comply with the necessary Federal requirements to conduct such activities using data collected via the registry (e.g., IRB review, Privacy Act and confidentiality expectations, Information Quality Guidelines, PRA submission and review). VA will provide the "privacy policy for Agent Orange registry examinations" associated with this package to all patients participating int he registry.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2020	36 Months From Approved
Responses	20,000	0	0
Time Burden (Hours)	6,667	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This records symptoms, reproductive health problems and diagnoses detected during the Agent Orange Registry examination process and identifies veterans interested in knowing of health risks, research findings and new compensation policies through newsletters.

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Authorizing Statute(s): PL: Pub.L. 100 - 687 Entirety Name of Law: Veterans' Judicial Review Act of 1988
   PL: Pub.L. 102 - 585 703 Name of Law: Veterans Health Care Act of 1992
   US Code: 38 USC Section 527 Name of Law: Evaluation and data collection
  

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:
	81 FR 69571	10/06/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 94484	12/23/2016
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
Agent Orange Registry Code Sheet	VA Form 10-9009	Agent Orange Registry Code Sheet

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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	20,000	0	0	0	0	20,000
Annual Time Burden (Hours)	6,667	0	0	0	0	6,667
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,677,220

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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:  No

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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: 12/30/2016

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