Information Collection

CHAMPVA Benefits - Application, Claim, OHI, Potential Liability & Spina Bifida

IC 28465 under ICR 200011-2900-005 · OMB 2900-0219.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	CHAMPVA Benefits - Application, Claim, OHI, Potential Liability & Spina Bifida	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	10-10D	Yes	Yes
Form	10-7959D	Yes	Yes
Form	10-7959A	Yes	Yes
Form	10-7959C	Yes	Yes
Form	10-7959E	Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 405,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 11 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	405,000	405,000
Annual IC Time Burden (Hours)	64,600	64,600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.