Request for Prescription Drugs from an Eligible Veteran in a State Home

Per Diem to States for Care of Eligible Veterans in State Homes

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0883 can be found here:

Documents and Forms

Document Name Document Type
Form 10-0460 Request for Prescription Drugs from an Eligible Veteran in a State Home Form
10-0460 Request for Prescription Drugs from an Eligible Veteran 10-0460-fill_Needs New OMB No and Expir Date.pdf www.va.gov/vaforms/ Form

Information Collection (IC) Details

IC Title:	Request for Prescription Drugs from an Eligible Veteran in a State Home	Agency IC Tracking Number:	2900-NEW

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 51

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-0460	Request for Prescription Drugs from an Eligible Veteran in a State Home	10-0460-fill_Needs New OMB No and Expir Date.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	11,000	11,000
Annual IC Time Burden (Hours)	5,500	5,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.