VA Form 21-0773 justification

Supporting Statement for VA Form 21-0773

Operation Enduring Freedom/Operation Iraqi Freedom Seriously Injured/Ill Service Member Veteran Worksheet, VA Form 21-0773

(2900-NEW)

A. Justification

1. The Department of Veterans Affairs (VA) through its Veterans Benefits Administration (VBA), administers an integrated program of benefits and services, established by law, for veterans, service personnel, and their dependents and/or beneficiaries. Title 5 U.S.C. 552(a) provides that the term ``maintain'' includes maintain, collect, use, or disseminate.

2. VA Form 21-0773 will be used, as recommended by President Bush’s Interagency Task Force on Returning Global War on Terror (GWOT) heroes, as a checklist for Veterans Service Representatives to verify they have given information, applications, and/or referral service to Operation Enduring Freedom or Operation Iraqi Freedom service members who have at least six months remaining on active duty and who may have suffered a serious injury or illness. This form will adhere to the Task Force recommendations to improve the timeliness, ease of application, and delivery of services and benefits to GWOT servicemembers . This form will be maintained in the veteran’s claims folder.

3. VA Form 21-0773 is a new form, which will become available on the VA Intranet web site in a fillable electronic format. VBA maintains a secure server for forms of this type. This form will not be made available to the public. It will serve as an information collection for verification VA is providing the veteran with benefit and entitlement information.

4. Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency, which maintains the necessary information, nor is it available from other sources within our Department.

5. The collection of information does not involve small businesses or entities.

6. This form is designed in a “user friendly” format, incorporating plain English, to comply with the President’s Memorandum of June 1, 1998, Plain Language in Government Writing.

7. There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.

8. The Department notice was published in the Federal Register on June 30, 2008, Volume 73, Number 126, Pages 36960-36961. There were no comments received in response to this notice.

9. No payments or gifts to respondents have been made under this collection of information.

10. The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22, "Compensation, Pension, Education and Rehabilitation Records - VA" as set forth in Privacy Act Issuances, 1993 compilation found in 42 Fed. Reg. 49726 (9/27//1977).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 153 per year.

b. Frequency of Response is one time for most beneficiaries.

c. Annual burden is 77 hours.

d. The estimated completion time of 30 minutes is based on review by staff personnel.

e. The total estimated cost to respondents is $1,155 (77 hours x $15/hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $4,898

(GS-12/5 @ $37.89 x 153 x 30 minutes = $2,899)

(GS-9/5 @ $26.13 x 153 x 30 minutes = $1,999)

b. Printing and production cost $390

c. Total cost to government $5,288

15. This is a new collection.

16. The information collection is not for publication or tabulation use.

17. The collection instrument, VA Form 21-0773, may be not reproduced and/or stocked by the respondents and veterans service organizations. This VA form does not display an expiration date, and if required to do so would result in unnecessary waste of existing stocks of this form. This form will be submitted to OMB every 3 years. As such, this date requirement would also result in an unnecessary burden on the respondents and would delay Department action. VA also seeks to minimize its cost to itself of collecting, processing and using the information by not displaying the expiration date. For the reasons stated, VA seeks an exemption that waives the displaying of the expiration date on VA Form 21-0773.

18. This submission does not contain any exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

This collection of informtion does not employ statistical methods.