Supporting Statement VA Form 26-0967 & 26-0967a

SUPPORTING STATEMENT

VA Form 26-0967, Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion, and VA Form 26-0967a, Specially Adaptive Housing Assistive Technology Grants Criteria and Responses (Documents and Information Required for Specially Adapted Housing Assistive Technology Grant

OMB 2900-0821
VA FORM 26-0967 and 26-0967A

A. Justification

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

Section 203 of the Veterans’ Benefits Act of 2010, Public Law 111-275, amended chapter 21, title 38, United States Code, to establish the Specially Adapted Housing (SAH) Assistive Technology Grant program. 38 U.S.C. 2108 states that a person or entity seeking an SAH technology grant shall submit an application for the grant in such form and manner as the Secretary shall specify. VA published regulations to outline the process, the criteria, and the priorities relating to the award of these research and development grants. 36 C.F.R. 4412(d)(2) requires applicants to submit VA Form 26-0967, Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion and VA Form 26-0967a, Specially Adaptive Housing Assistive Technology Grants Criteria and Responses. 36 C.F.R. 4412(d)(3) require applicants to provide statements addressing six scoring criteria for grant awards as part of their application. Lastly, 36 C.F.R. 4412(d)(1) require that applicants submit Standard Form 424, Application for Federal Assistance, which is covered under an existing information collection (OMB Number: 4040-0004). The final rule was published on September 17, 2015 (80 FR 55763-55766).

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

Non-Federal entities (state and local governments, and non-profit organizations), private entities, and individuals may submit this information to complete an application for the SAH Assistive Technology Grant program. Applicants may either obtain printed copies of the forms or electronically download the required forms. These forms and other required statements are then completed and the applications submitted to VA electronically through Grants.gov. The signed forms provide certification of compliance with VA grant requirements. VA will use all information summited by applicants, including the SF 424, VA Form 26-0967 and VA Form 26-0967a. The information will be used by Loan Guaranty personnel in deciding whether an applicant meets the requirements and satisfies the scoring criteria for award of an SAH Assistive Technology grant under 38 U.S.C. 2108.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

Applicants for an SAH Assistive Technology grant will submit their applications to the Secretary via Grants.gov. Grants.gov provides a centralized location for federal agencies to post discretionary funding opportunities and grant seekers to find and apply for federal funding opportunities. Electronic submission through this centralized website will reduce the burden on applicants and VA and will improve consistency in submissions. VA will use the information contained in Standard Form 424, VA Form 26-0967 and VA Form 26-0967a. These forms will be accessed and downloaded at the One-VA Forms Site (http://vaww4.va.gov/vaforms/) and Grants.gov (http://www.grants.gov). These signed forms will provide applicant certification of compliance with VA grant requirements. VA will use this information to award SAH Assistive Technology grants.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or agency which maintains the necessary information, nor is it available from other sources within our Department.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The collection of information will affect non-Federal entities, private entities, and individuals who chose to submit applications for the SAH Assistive Technology grant. This information collection is limited to determining whether, and to what degree, the applicant meets the requirements used in the award process of SAH Assistive Technology grants. Applicants may only apply for one grant per year, and once per project, in the maximum amount of $200,000 per project. Therefore, this information is considered to only be collected one time, and may be submitted electronically, which lessens the burden on any small businesses or other small entities who choose to submit applications.

6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

This information is collected only when a non-Federal entity, private entity, or individual wishes to apply for a SAH Assistive Technology grant. This information is essential the SAH Assistive Technology grant applications, the form and manner of which the Secretary is describing in proposed regulations pursuant to 38 U.S.C. 2108. The collection is generally conducted only one time, at the time of application submission. If this information was collected less frequently, VA would be unable to adequately assess applications or perform its statutory obligation to administer the program.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The Department notice was published in the Federal Register on 04/06/2021, Volume 86, No 64, pages 17891.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payments or gifts to respondents have been made under this collection of information.

10. Describe any assurance of privacy, to the extent permitted by law, provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

Loan Guaranty Fee Personnel and Program Participant Records—VA. (17VA26) contained in the Privacy Act Issuances 2014 Compilation.

11. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature.

12. Estimate of the hour burden of the collection of information:

Estimate of Information Collection Burden.

1. Number of Respondents: 20

1. Frequency of Response: Once [20 X 20 / 60] = 7

2. Annual Burden Hours: 40

2. Estimated Completion Time: 2 hours

2. The respondent population for VA Form 26-0967 and VA Form 26-0967A is composed of individuals who are competing for grants of financial assistance through the SAHAT grant program to develop new assistive technology. VA cannot make further assumptions about the population of respondents because of the variability of factors such as the educational background and wage potential of respondents. Therefore, VBA used general wage data to estimate the respondents’ costs associated with completing the information collection.

The Bureau of Labor Statistics (BLS) gathers information on full-time wage and salary workers. According to the latest available BLS data, the mean hourly wage is $25.72 based on the BLS wage code – “00-0000 All Occupations.” This information was taken from the following website: https://www.bls.gov/oes/current/oes_nat.htm .

Legally, respondents may not pay a person or business for assistance in completing the information collection. Therefore, there are no expected overhead costs for completing the information collection. VBA estimates the total cost to all respondents to be $1,029 (40 burden hours x $25.72 per hour).

13. Provide an estimate of the total annual cost burden to respondents or record-keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

This submission does not involve any recordkeeping costs.

14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

Estimated Costs to the Federal Government:

Grade	Step	Burden Time Employee	Hourly Wage Rate	Cost per Response	Total Responses	Gov. Cost
13	1	15min	$38.08	$9.52 (.25X38.08)	40	$380.80
	Overhead at 100%. Overhead costs are 100% of salary, which are also the same as the wage listed above; and the amount is included in the total.
	Total Cost to Government					$380.80

Overhead costs are 100% of salary and are the same as the wage listed above and the amounts are included in the total.

Printing and production costs approximates the cost of printing this information collection per year. (Processing/Analyzing Cost total divided by $90).

Note: The hourly wage information above is based on the hourly 2021 General Schedule (Base) Pay (https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2021/GS_h.pdf) . This rate does not include any locality adjustment as applicable.

The processing time estimates above are based on the actual amount of time employees of each grade level spend to process a claim received on this form. The within-grade step (1) of each employee represents the average experience of employees within each grade.

15. Explain the reason for any burden hour changes since the last submission.

There is no change in the burden hours.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

VA does not publish this information or make it available for publication.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

We are not seeking approval to omit the expiration date for OMB approval.

18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

There is no exception to the certification statement identified in Item 19,

"Certification for Paperwork Reduction Act Submissions," of OMB Form 83-l.

B. Collection of Information Employing Statistical Methods

This collection of information by the Veterans Benefits Administration does not employ statistical methods.

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