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

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 0857A Written Confirmation of Request for Accommodation Written Confirmation of Request for Accommodation; Authorization for Limited Release of Medical Information	Form
Form VA Form 0857d Authorization for Limited Release of Medical Information 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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 0857A				No		Paper Only
Form	VA Form 0857d				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 %

table that charts list of burden
	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

table that charts IC Documents
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.

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