Foreign Medical Program

Forms and Documents

Document Name	Status
Form 10-7959f-2 Claim Cover Sheet for Foreign Medical Program Form	Modified
2900-0648 justification.doc Supporting Statement A	2006-08-24

IC Document Collections

IC ID	Document Title	Status
28924	Claim Cover Sheet for Foreign Medical Program Form	Modified

ICR Details

OMB Control No: 2900-0648	ICR Reference No: 200608-2900-008
Status: Historical Active	Previous ICR Reference No: 200308-2900-005
Agency/Subagency: VA	Agency Tracking No:
Title: Foreign Medical Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/11/2006
	Date Received in OIRA: 08/30/2006
Terms of Clearance: Approved consistent with the following terms of clearance: in the next submission of this collection to OMB VA shall provide an update on the status of Dept. efforts to provide a fully electronic capability for the completion and submission of associated forms.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2009	36 Months From Approved	10/31/2006
Responses	21,580	0	19,920
Time Burden (Hours)	3,762	0	3,652
Cost Burden (Dollars)	0	0	0

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Abstract: Optional form used to determine appropriateness of payment for claims submitted for payment/reimbursement of medical expenses related to veterans with a service-connected disability who are overseas (except for Canada and the Phillipines).

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 105	06/01/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 157	08/15/2006
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Claim Cover Sheet for Foreign Medical Program	10-7959f-1, 10-7959f-2	Claim Cover Sheet - Foreign Medical Program (FMP) ,   Foreign Medical Program (FMP) Registration Form

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ICR Summary of Burden

	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	21,580	19,920	0	1,660	0	0
Annual Time Burden (Hours)	3,762	3,652	0	110	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The 1,660 responses and the 110 burden hours associated with the new form 10-7959f-1 are considered a Program Increase.

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Annual Cost to Federal Government: $24,223

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/30/2006

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