Agency Information Collection (Application for Extended Care Services); Activity Under OMB Review

Summary:

In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-21), this notice announces that the Veterans Health Administration (VHA), Department of Veterans Affairs, will submit the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden; it includes the actual data collection instrument.

Dates:

Comments must be submitted on or before August 22, 2011.

Addresses:

Submit written comments on the collection of information through http://www.Regulations.gov; or to VA's OMB Desk Officer, OMB Human Resources and Housing Branch, New Executive Office Building, Room 10235, Washington, DC 20503 (202) 395-7316. Please refer to “OMB Control No. 2900-0629” in any correspondence.

For further information contact:

Denise McLamb, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 461-7485, fax (202) 461-0966 or e-mail denise.mclamb@va.gov. Please refer to “OMB Control No. 2900-0629.”

Supplementary information:

Title: Application for Extended Care Services, VA Form 10-10EC.

OMB Control Number:2900-0629.

Type of Review: Extension of a currently approved collection.

Abstract: VA Form 10-10EC is used to gather current income and financial information from nonservice-connected veterans and their spouse when applying for extended care services and to establish a co-payment agreement for such services. VA provides extended care to non-service connected veterans who are unable to defray the necessary expenses of care if their income is not greater than the maximum annual pension rate. VA uses the data collected to establish the veteran's eligibility for extended care services, financial liability, if any, of the veteran to pay if accepted for placement or treatment in extended care services, and to determine the appropriate co-payment.

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published on May 18, 2011, at pages 28851-28852.

Affected Public: Individuals or Households.

Estimated Total Annual Burden:9,000 hours.

Estimated Average Burden per Respondent:90 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents:6,000.

Dated: July 19, 2011.

By direction of the Secretary.

Denise McLamb,

Program Analyst, Enterprise Records Service.

References

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