SUPPORTING STATEMENT A
Camp Lejeune Family Member Program (CLFMP)
Reimbursement of Certain Medical Expenses
VA
Forms: 10-10068, 10-10068a, 10-10068b, 10-10068c
OMB
Control Number: 2900-0822
Summary:
VA Form 10-10068b has been revised with some minor changes to the wording to clarify the information being collected from the treating physician.
VA Form 10-10068b may now be used up to two times annually per patient, and there is an associated increase in the estimated burden hours.
VA received one comment on the 60-day FRN.
1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
Under 38 U.S.C. 1787, VA is required to furnish hospital care and medical services to the family members of certain veterans who were stationed at Camp Lejeune between 1953 and 1987. In order to furnish such care, VA must collect necessary information from the family members to ensure that they meet the requirements of the law. The specific hospital care and medical services that VA must provide are for a number of illnesses and conditions connected to exposure to contaminated drinking water while at Camp Lejeune. VA will furnish Camp Lejeune family members with hospital care and medical services for 15 illnesses and conditions that are life threatening and require immediate medical intervention. The forms in this collection will be used to determine eligibility and reimbursement for this medical care. Some minor changes to the wording in VA Form 10-10068b have been made to clarify the information being collected from the treating physician.
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.
VA will use this information collection to furnish hospital care and medical services to Camp Lejeune family members. VA will use VA Form 10-10EZ (2900-0091) to confirm Veteran self-election check box for serving at Camp Lejeune. VA will also use CMS 1500 and UB-04 (not on file as a common form in ROCIS) to file with Medicare/Medicaid.
10-10068 -- CLFMP Application: CL family members will use this form to apply for acceptance for benefits under the Camp Lejeune Family Member Program.
10-10068a -- CLFMP Claim Form: CL family members will use this form to submit medical bills for reimbursement.
10-10068b -- CLFMP Treating Physician Report: This Record of Examination must be completed by family member’s treating physician. The physician will use this form if the family member has one of the 15 covered conditions. This form is used both for the initial eligibility review to make a determination of a possible approved condition and also to determine if a person should remain on the active list for comprehensive coverage due to continuous treatment, which typically covers 6-month intervals (or twice annually).
10-10068c -- CLFMP Information Update Form: The CL family members will use this form to update their information for the program.
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.
At program startup, there was limited functionality for electronic means to apply for the program and for physicians to submit claims via EDI. Future phases of the system used for the program allow for more electronic functionality to be available to provide information updates.
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.
Form 10-10068: No other method currently exists for obtaining correct CL family member identifiers, demographics and other information needed for processing applications.
Form 10-10068a: No other method currently exists for obtaining correct CL family member identifiers, demographics and other information needed for processing medical claims.
Form 10-10068b: No other method currently exists for obtaining correct CL family member identifiers, demographics and other information needed for identifying the medical conditions for which respondent is applying for care reimbursement.
Form 10-10068c: No other method currently exists for obtaining correct CL family member identifiers, demographics and other information needed for updating family member information.
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 have no impact on small businesses or other small entities.
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.
If the collection is not conducted, then VA cannot appropriately identify Camp Lejeune family members or furnish hospital care and medical services to these individuals through the payment or reimbursement of care related to the illnesses and conditions specified in 38 U.S.C. 1787.
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 are no such special circumstances.
8. a. 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.
A 60-Day Federal Register Notice (FRN) for the collection published on Thursday, May 29, 2025. The 60-Day FRN citation is 90 FR 22832. VA received one public comment on the 60-day FRN. The VA response will be provided in a separate document in the PRA package for this ICR. However, no changes will be made to the information collection as a result of the comment.
A 30-Day Federal Register Notice for the collection published on Friday, August 1, 2025. The 30-Day FRN citation is 90 FR 36286.
b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.
Outside consultation is conducted with the public through the 60- and 30-day Federal Register notices.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payment or gift is provided to respondents.
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.
Assurances of privacy are contained in 38 U.S.C. 5701 and 7332. Respondents are informed that the information collected will become part of the Consolidated Health Record that complies with the Privacy Act of 1974. These forms are part of the system of records identified as 23VA16 “Patient Medical Record – VA” as set forth in the Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html.
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:
a. The number of respondents, frequency of responses, annual hour burden, and explanation for each form is reported as follows:
Total Annual Number of Responses: 23,349
Total Annual Time Burden: 6,246 hours
VA Form(s) |
No. of respondents |
Times per year |
= No. of responses |
x No. of minutes |
÷ by 60 =
|
Number of Burden Hours |
10-10068 |
1,629 |
1/yr |
1,629 |
30 min |
815 |
|
10-10068a |
1,629 |
11/yr |
17,919 |
15 min |
|
4,480 |
10-10068b |
1,629 |
2/yr |
3,258 |
15 min |
|
815 |
10-10068c |
543 |
1/yr |
543 |
15 min |
|
136 |
Total |
5,430 |
|
23,349 |
|
|
6,246 hours |
b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.
This request covers 4 forms, See chart in subparagraph 12a above.
c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.
VA cannot make assumptions about the population of respondents because of the variability of factors, such as the educational background and wage potential of respondents. Therefore, VHA 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 $31.48 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 $196,624.08 (6,246 burden hours x $31.48 per hour).
13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).
a. There are no capital, start-up, operation, or maintenance costs.
b. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.
c. There is no anticipated recordkeeping burden beyond that which is considered usual and customary.
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.
(Based on the hourly salary of a GS 7 Step 5.)
The estimated annual cost of VA Form 10-10068 to the Federal Government is $25,387.
The estimated annual cost of VA Form 10-10068a to the Federal Government is $139,552.
The estimated annual cost of VA Form 10-10068b to the Federal Government is $25,387.
The estimated annual cost of VA Form 10-10068c to the Federal Government is $4,236.
Form |
Hourly Salary |
Responses |
Time to Complete |
Total Hours |
Cost |
10-10068 |
$31.15 |
1,629 |
30 minutes |
815 |
$ 25,387 |
10-10068a |
$31.15 |
17,919 |
15 minutes |
4,480 |
$139,552 |
10-10068b |
$31.15 |
3,258 |
15 minutes |
815 |
$ 25,387 |
10-10068c |
$31.15 |
543 |
15 minutes |
136 |
$ 4,236 |
|
TOTAL |
$194,562 |
|||
15. Explain the reason for any burden hour changes or adjustments reported in items 13 or 14 of the OMB form 83-1.
The burden hours have increased due to an increase in the use of VA Form 10-10068b.
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 intend to publish this data.
17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
VA will display the expiration date on all forms.
18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.
There are no exceptions.
Page
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Bold black = OMB questions |
| Author | vhacobickoa |
| File Modified | 0000-00-00 |
| File Created | 2025-08-02 |