Survey of Chronic Gastrointestinal Illness in Persian Gulf Veterans (Irritable Bowel Syndrome - Diarrhea)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-21092B Patient Consent Form - Controls Study	Form and Instruction	New	Available
Form VA Form 10-21092A Patient Consent Form - Cases Study	Form and Instruction	New	Available
Form VA Form 10-21092c Survey of Chronic Gastrointestinal Illness in Persian Gulf Veterans	Form and Instruction	New	Available
Colonoscopy Consent Form.pdf	Supplementary Document	Uploaded 2009-09-29	Available
VA Form 10-21092a-c justification.doc	Supporting Statement A	Uploaded 2009-10-05	Available
10-21092a Survey Cover Letter.doc	Supplementary Document	Uploaded 2009-09-28	Available
Justification B (v2).doc	Supporting Statement B	Uploaded 2009-08-26	Available
Gulf IBS Study IRB Approval 2009.pdf	Supplementary Document	Uploaded 2009-04-29	Available
Patient Introductory Letter.doc	Supplementary Document	Uploaded 2009-04-29	Available
Patient 2nd Response Letter.doc	Supplementary Document	Uploaded 2009-02-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
188135	Survey of Chronic Gastrointestinal Illness inPersian Gulf Veterans (Irritaable Bowel syndrome - Diarrhea)	Form and Instruction	New	Patient Consent Form - Controls Study
188135	Survey of Chronic Gastrointestinal Illness inPersian Gulf Veterans (Irritaable Bowel syndrome - Diarrhea)	Form and Instruction	New	Patient Consent Form - Cases Study
188135	Survey of Chronic Gastrointestinal Illness inPersian Gulf Veterans (Irritaable Bowel syndrome - Diarrhea)	Form and Instruction	New	Survey of Chronic Gastrointestinal Illness in Persian Gulf Veterans

ICR Details

OMB Control No: 2900-0742	ICR Reference No: 200902-2900-012
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Survey of Chronic Gastrointestinal Illness in Persian Gulf Veterans (Irritable Bowel Syndrome - Diarrhea)
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 without change	Conclusion Date: 01/27/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/05/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2013	36 Months From Approved
Responses	4,000	0	0
Time Burden (Hours)	3,072	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 700,00 U.S. military troops were deployed in the first Persian Gulf War. Upon return, nearly 25% of those Veterans had persistent gastrointestinal symptoms, typical of diarrhea-predominant irritable bowl syndrome (IBS). This is suspected to be related to their military service in the Gulf. Collection of data will allow VA to measure and evaluate the burden of chronic gastrointestinal illness and the goal of which is improved healthcare for Veterans.

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Authorizing Statute(s): US Code: 38 USC Part 1, Chapter 5, Section 527 Name of Law: Veterans Benefits
  

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:
	74 FR 89	05/11/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 141	07/24/2009
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
Survey of Chronic Gastrointestinal Illness inPersian Gulf Veterans (Irritaable Bowel syndrome - Diarrhea)	VA Form 10-21092A, VA Form 10-21092B, VA Form 10-21092c	Survey of Chronic Gastrointestinal Illness in Persian Gulf Veterans ,   Patient Consent Form - Cases Study ,   Patient Consent Form - Controls Study

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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	4,000	0	0	4,000	0	0
Annual Time Burden (Hours)	3,072	0	0	3,072	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: This is a new information collection.

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Annual Cost to Federal Government: $53,260

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)? No

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: 10/05/2009

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