VA Advance Directive - Durable Power of Attorney for Health Care and Living Will (VA Form 10-0137)

Forms and Documents

Document Name	Status
Form 10-0137 VA Form 10-0137 Form and Instruction	Modified
30-day FRN_2900-0556_VA Advance Directive_POA for Health Care & Living Will_published 02122021.pdf Supplementary Document	2021-02-18
60-day FRN_2900-0556_VA Advance Directive_POA for Health Care & Living Will_pub 100820.pdf Supplementary Document	2020-11-28
2900-0556_Supp Stmnt A_VA Adv Directive_POA for Health Care & Living Will_updated Feb 2021.docx Supporting Statement A	2021-02-18

IC Document Collections

IC ID	Document Title	Status
242471	VA Form 10-0137 Form and Instruction	Modified
241723	Close Personal Friend Statement of Relationship to Veteran	Modified

ICR Details

OMB Control No: 2900-0556	ICR Reference No: 202010-2900-001
Status: Received in OIRA	Previous ICR Reference No: 202006-2900-009
Agency/Subagency: VA	Agency Tracking No: 2900-0556
Title: VA Advance Directive - Durable Power of Attorney for Health Care and Living Will (VA Form 10-0137)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/18/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	343,922	0
Time Burden (Hours)	171,861	0
Cost Burden (Dollars)	0	0

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Abstract: Section 7331 of title 38, United States Code (U.S.C.), requires, in relevant part, that the Secretary of Veterans Affairs, upon the recommendation of the Under Secretary for Health, prescribe regulations to ensure, to the maximum extent practicable, that all VA patient care be carried out only with the full and informed consent of the patient, or in appropriate cases, a representative thereof. Based on VA’s interpretation of this statute and our mandate in 38 U.S.C. 7301(b) to provide a complete medical and hospital service, we recognize that patients with decision-making capacity have the right to state their treatment preferences in a VA or other valid advance directive. The VA advance directive form (both English and Spanish language versions) is VA Form 10-0137. These forms have a current OMB Paperwork Reduction Act (PRA) clearance under OMB Control Number 2900-0556. In addition, 2900-0556 now includes the collection of a “Close Personal Friend Statement” for incapacitated Veterans who have not completed an Advance Directive and are in need of health care. When a Veteran is incapacitated and does not have an Advance Directive, the VA regulations allow a statement to be submitted from a “Close Personal Friend” who will be responsible for making health care decisions on behalf of the Veteran. It is estimated that 300 such statements will be collected annually.

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Authorizing Statute(s): US Code: 38 USC 7331 Name of Law: Informed consent
  

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 63661	10/08/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 9424	02/12/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Close Personal Friend Statement of Relationship to Veteran
VA Form 10-0137	10-0137, 10-0137	VA Advance Directive - Durable Power of Attorney for Health Care and Living Will ,   VA Advance Directive - Durable Power of Atttorney for Health Care and Living WIll (English-Spanish)

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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	343,922	0	0	0	0	343,922
Annual Time Burden (Hours)	171,861	0	0	0	0	171,861
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: $6,379,342

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: 02/18/2021

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