Chapter 31 Request for Assistance (VA Form 28-10212)

Forms and Documents

Document Name	Status
Form VA Form 28-10212 Chapter 31 Request for Assistance (VA Form 28-10212) Form	Modified
2020-26566.pdf Supplementary Document	2020-12-02
SupportStatement(2900-0882) (1).docx Supporting Statement A	2020-11-24
2020-20650.pdf Supplementary Document	2020-09-18

IC Document Collections

IC ID	Document Title	Status
242785	Chapter 31 Request for Assistance (VA Form 28-10212) Form	Modified

ICR Details

OMB Control No: 2900-0882	ICR Reference No: 202009-2900-003
Status: Received in OIRA	Previous ICR Reference No: 202007-2900-018
Agency/Subagency: VA	Agency Tracking No: VBA-VR&E-NK
Title: Chapter 31 Request for Assistance (VA Form 28-10212)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 12/30/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2021
Responses	500	500
Time Burden (Hours)	83	83
Cost Burden (Dollars)	0	0

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Abstract: VA Form 28-10212 is used by claimants to request specific services, supplies, and equipment to participate in their rehabilitation program under the provisions of 38 U.S.C. 3100.

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Authorizing Statute(s): US Code: 38 USC 5101(a) Name of Law: Claims and Forms
   US Code: 38 USC 3100 Name of Law: Purposes
   US Code: 38 USC 501 Name of Law: Rules and Regulations
  

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:
	85 FR 20650	09/18/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 26566	12/02/2020
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
Chapter 31 Request for Assistance (VA Form 28-10212)	VA Form 28-10212	Chapter 31 Request for Assistance

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ICR Summary of Burden

	Total Request	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	500	500	0	0	0	0
Annual Time Burden (Hours)	83	83	0	0	0	0
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: $27,810

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? No

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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: 12/30/2020

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