Health Insurance and Key Driver Modules - Survey of Veteran Enrollees' Health and Reliance Upon VA

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-21034k Cover Sheet for Key Drivers Module 2	Form	New	Available
Form VA Form 10-21034j Cover Sheet for Health Insurance Module 1	Form	New	Available
Form VA Form 10-21034j Health Insurance Module 1	Form	New	Available
Form VA Form 10-21034k Key Drivers Module 2	Form	New	Available
10-21034k module 2 from p2 v4.xls	Supplementary Document	Uploaded 2007-01-08	Available
2900-New 10-21034j-k justification Part B.doc	Supporting Statement B	Uploaded 2006-10-10	Available
2900-New 10-21034j-k justification Part A.doc	Supporting Statement A	Uploaded 2006-10-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
45604	Health Insurance and Key Driver Modules - Survey of Veteran Enrollees' Health and Reliance Upon VA	Form	New	Cover Sheet for Key Drivers Module 2
45604	Health Insurance and Key Driver Modules - Survey of Veteran Enrollees' Health and Reliance Upon VA	Form	New	Cover Sheet for Health Insurance Module 1
45604	Health Insurance and Key Driver Modules - Survey of Veteran Enrollees' Health and Reliance Upon VA	Form	New	Health Insurance Module 1
45604	Health Insurance and Key Driver Modules - Survey of Veteran Enrollees' Health and Reliance Upon VA	Form	New	Key Drivers Module 2

ICR Details

OMB Control No: 2900-0693	ICR Reference No: 200610-2900-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Health Insurance and Key Driver Modules - Survey of Veteran Enrollees' Health and Reliance Upon VA
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/09/2007
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/16/2006
Terms of Clearance: Approved consistent with changes to the questionnaire submitted by VA memo and included in the electronic docket. In the next submission of OMB number 2900-0609, VA shall combine this collection and 2900-0609 into a single submission. Additionally, OMB continues to encourage VA to work with their contractor to enhance the coding of case level outcomes to better understand reasons for nonresponse and conduct research that may include tracing veterans with inadequate contact information, increasing the number of call attempts, and testing strategies for identifying and handling veterans in institutions, etc, under 2900-0609. Should VA develop plans for related substudies, the Department should consult with and seek clearance from OMB through administrative change requests (83-Cs).

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2010	36 Months From Approved
Responses	44,000	0	0
Time Burden (Hours)	3,168	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: These frequently changing modules will be added to the more stable core questions to provide information for planning & policy development for actuarial projections of enrollment, utilization, expenditures, mandated annual enrollment reforms, & quantitative & qualitative research.

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Authorizing Statute(s): US Code: 38 USC 501 Name of Law: Rules and Regulations
   PL: Pub.L. 104 - 262 101-207 Name of Law: Eligibility Reform
  

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 118	06/20/2006
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
Health Insurance and Key Driver Modules - Survey of Veteran Enrollees' Health and Reliance Upon VA	VA Form 10-21034k, VA Form 10-21034j, VA Form 10-21034k, VA Form 10-21034j	Health Insurance Module 1 ,   Cover Sheet for Health Insurance Module 1 ,   Cover Sheet for Key Drivers Module 2 ,   Key Drivers Module 2

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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	44,000	0	0	44,000	0	0
Annual Time Burden (Hours)	3,168	0	0	3,168	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: These modules (with a new approval number) will be added to the questions currently approved under 2900-0609. Although questions of this nature have been asked in the past, they are now considered a program increase of 3,168 burden hours

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Annual Cost to Federal Government: $255,275

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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