Information Collection

Written Confirmation of Request for Accommodation; Authorization for Limited Release of Medical Information

IC 192637 under ICR 201004-2900-003 · OMB 2900-0767.

Documents and Forms

Document Name Document Type
Form VA Form 0857A Written Confirmation of Request for Accommodation; Authorization for Limited Release of Medical Information Form
VA Form 0857A Written Confirmation of Request for Accommodation VA0857A.pdf Form
VA Form 0857d Authorization for Limited Release of Medical Information VA0857d.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Written Confirmation of Request for Accommodation; Authorization for Limited Release of Medical Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 0857A	Written Confirmation of Request for Accommodation	VA0857A.pdf		No		Paper Only
Form	VA Form 0857d	Authorization for Limited Release of Medical Information	VA0857d.pdf		No		Paper Only

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	18	18
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.