OMB28-0791(6-10-09)

Supporting Statement for

Preliminary Independent Living (IL) Assessment

VA Form 28-0791 (2900-0681)

A. Justification

1. Under 38 U.S.C. 3104(a)(1), 3109 and 38 CFR 21.50, 21.160, and 21.162, the Department of Veterans Affairs (VA) collects information from disabled veterans to determine the scope of their potential IL needs under the Vocational Rehabilitation and Employment program.

2. This form will be used by case managers during the initial IL evaluation. During this face-to-face meeting, the case manager investigates difficulties the veteran may be experiencing in a wide range of areas. The case manager then uses this information to schedule additional assessments of capability and functioning and determines needed interventions.

3. VA does not use information technology to collect this information, since open-ended questioning may be needed to obtain complete information.

4. This information is not available from any other source. It is based upon each veteran’s perception of his/or her capabilities.

5. The collection of information will not have any impact upon small businesses or other small entities.

6. The collection of this information is required by law (38 U.S.C. 3104 (a)(1) and 3109). Failure to collect this information would have a detrimental impact upon the determination of appropriate rehabilitation goals for veterans participating in the independent living program.

7. There are no special circumstances that impose any exceptional burdens on respondents.

8. The Department notice was published in the Federal Register on April 3, 2009 at pages 15325-15326. One comment was received.

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

10. Clients are assured of confidentiality of their responses under Compensation, Pension, Education and Rehabilitation Records- VA(58VA21/22), contained in the Privacy Act Issuances, 2001 Compilation.

11. This form collects potentially sensitive information. Questions are included which pertain to Alcohol/Substance Abuse and Personal, Emotional, and Spiritual Needs. These questions are necessary because they address issues which can have a significant impact upon the veteran’s ability to profit from vocational rehabilitation services, and also because they may indicate areas in which therapeutic intervention is needed. Responses to questions in the aforementioned areas will only be used for the purpose of determining the ability of the veteran to profit from participation in the IL program and/or the veteran’s need for assistance. Prior to completion of this form, each veteran will have signed a Protection of Privacy Information Statement, VA Form 28-8739a.

12. Estimate of Annual Information Collection Burden

a.	Number of estimated respondents:	2,500
b.	Frequency of response:	One-time
c.	Annual burden hours:	2,500 hours
d.	The estimated completion time of one hour is based upon test interviews.
e.	2,500 responses x $15.00 per hour = $37,500

13. This submission does not involve any recordkeeping costs.

14. Estimated Annual Cost to the Federal Government

a.	Annual cost for processing this form [2,500 responses x 1 hour x $31.06/hour (a case manager’s average grade of GS 12/3)]:	$77,650
b.	Printing and design costs:	$360
c.	Total cost:	$78,010

15. There is no change in burden.

16. VA will not tabulate or publish this information collection.

17. VA Form 28-0791, Preliminary IL Assessment, is the major source for the collection of information vital to the case manager’s evaluation of a veteran’s potential independent living needs. If this form were to display an expiration date, there may be an unnecessary waste of existing future stocks. This form will be submitted to OMB every three years. VA seeks to reduce its costs for collecting, processing, and using the information by not displaying the expiration date. For these reasons, VA seeks exemption from displaying the expiration date on this form.

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

B. Collections of Information Employing Statistical Methods

The data collection does not employ statistical methods.

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