Advanced Directive - Living Will and Durable Power of Attorney

ICR 200509-2900-001

OMB: 2900-0556

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
2900-0556 200509-2900-001
Historical Active 200208-2900-004
VA
Advanced Directive - Living Will and Durable Power of Attorney
Revision of a currently approved collection   No
Regular
Approved with change 11/29/2005
Retrieve Notice of Action (NOA) 09/09/2005
  Inventory as of this Action Requested Previously Approved
11/30/2008 11/30/2008 11/30/2005
256,253 0 243,000
128,127 0 101,250
0 0 0

This is used exclusively by VA patients to given specific instructions about their treatment preferences in the event they are no longer competent or able to verbally express these instructions. This voluntary information is collected at admission to the medical center and then filed into the patient's medical record.

None
None


No

1
IC Title Form No. Form Name
Advanced Directive - Living Will and Durable Power of Attorney 10-0137

  Total Approved 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 256,253 243,000 0 0 13,253 0
Annual Time Burden (Hours) 128,127 101,250 0 0 26,877 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
09/09/2005


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