VA Cooperative Study Project #500A, National Registry of Veterans with Amyotrophic Lateral Sclerosis (ALS)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-21047b Verbal Informed Consent VIA Telephone, National Registry of Veterans with ALS	Form	Modified	Repair queued
Form VA Form 10-21047 ALS Registry Screening Form	Form	Modified	Available
Form VA Form 10-21047a Biannual Telephone Interview, National Registry of Veterans with ALS	Form	Modified	Available
2900-0649 Justification Part B.doc	Supporting Statement B	Uploaded 2006-10-06	Available
2900-0649 Justification Part A.doc	Supporting Statement A	Uploaded 2006-10-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28925	VA Cooperative Study Project #500A, National Registry of Veterans with Amyotrophic Lateral Sclerosis (ALS)	Form	Modified	Verbal Informed Consent VIA Telephone, National Registry of Veterans with ALS
28925	VA Cooperative Study Project #500A, National Registry of Veterans with Amyotrophic Lateral Sclerosis (ALS)	Form	Modified	ALS Registry Screening Form
28925	VA Cooperative Study Project #500A, National Registry of Veterans with Amyotrophic Lateral Sclerosis (ALS)	Form	Modified	Biannual Telephone Interview, National Registry of Veterans with ALS

ICR Details

OMB Control No: 2900-0649	ICR Reference No: 200610-2900-002
Status: Historical Active	Previous ICR Reference No: 200309-2900-003
Agency/Subagency: VA	Agency Tracking No:
Title: VA Cooperative Study Project #500A, National Registry of Veterans with Amyotrophic Lateral Sclerosis (ALS)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/15/2006
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/16/2006
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2009	36 Months From Approved	12/31/2006
Responses	2,740	0	3,822
Time Burden (Hours)	1,296	0	1,808
Cost Burden (Dollars)	0	0	0

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Abstract: Purpose is to provide epidemiological data on the natural history of ALS, current population of veterans with ALS, provide ongoing identification of new cases,provide means of informing veterans of new clinical trials and studies, help VA to understand how veterans are affected by ALS and may also assist with the early identification of new ALS clusters.

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Authorizing Statute(s): US Code: 38 USC 527 Name of Law: Evaluation and data collection
  

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 157	08/15/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 194	10/06/2006
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
VA Cooperative Study Project #500A, National Registry of Veterans with Amyotrophic Lateral Sclerosis (ALS)	VA Form 10-21047, VA Form 10-21047a, VA Form 10-21047b	ALS Registry Screening Form ,   Biannual Telephone Interview, National Registry of Veterans with ALS ,   Verbal Informed Consent VIA Telephone, National Registry of Veterans with ALS

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ICR Summary of Burden

table that charts list 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	2,740	3,822	0	-1,082	0	0
Annual Time Burden (Hours)	1,296	1,808	0	0	-512	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: The number of new baseline screenings and biannual interviews differ from prior years. New baseline screenings are fewer, since incident (new) cases are primarily enrolled and prevalent (existing) cases have already been enrolled from when the study began. In addition, the numbers reported are based on experience from the first three years of this project, rather than the estimated projections before the study began.

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Annual Cost to Federal Government: $120,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 10/16/2006

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