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

ICR 202009-2900-003

OMB: 2900-0882

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2020-12-02
Supporting Statement A
2020-11-24
Supplementary Document
2020-09-18
IC Document Collections
IC ID
Document
Title
Status
242785 Modified
ICR Details
2900-0882 202009-2900-003
Received in OIRA 202007-2900-018
VA VBA-VR&E-NK
Chapter 31 Request for Assistance (VA Form 28-10212)
Extension without change of a currently approved collection   No
Regular 12/30/2020
  Requested Previously Approved
36 Months From Approved 02/28/2021
500 500
83 83
0 0

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.

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
  
None

Not associated with rulemaking

  85 FR 20650 09/18/2020
85 FR 26566 12/02/2020
No

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

  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
No
No

$27,810
No
    Yes
    Yes
No
No
No
No
Danny Green 202 421-1354 danny.green2@va.gov

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
12/30/2020


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