Report of Treatment in Hospital

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FL 29-551 Report of Treatment in Hospital	Form	Unchanged	Available
2900-0119 justification.docx	Supporting Statement A	Uploaded 2011-09-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28329	Report of Treatment in Hospital	Form	Unchanged

ICR Details

OMB Control No: 2900-0119	ICR Reference No: 201106-2900-004
Status: Historical Active	Previous ICR Reference No: 200805-2900-011
Agency/Subagency: VA	Agency Tracking No: 2900-0119
Title: Report of Treatment in Hospital
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/16/2012
	Date Received in OIRA: 09/23/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	36 Months From Approved	01/31/2012
Responses	20,277	0	20,277
Time Burden (Hours)	4,055	0	4,055
Cost Burden (Dollars)	0	0	0

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Abstract: This form letter is used to collect information from the insured's hospital to determine eligibility for a claim. The information is required by law, 38 USC 1912, 1915, 1942 and 1948.

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Authorizing Statute(s): US Code: 38 USC 1942 Name of Law: Plans of Insurance
   US Code: 38 USC 1948 Name of Law: Total Disability Provision
   US Code: 38 USC 1912 Name of Law: Total Disability Waiver
   US Code: 38 USC 1915 Name of Law: Totla Disability Income Provision
  

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:
	76 FR 127	07/01/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 177	09/13/2011
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
Report of Treatment in Hospital	FL 29-551	Report of Treatment in Hospital

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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	20,277	20,277	0	0	0	0
Annual Time Burden (Hours)	4,055	4,055	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $137,680

Does this IC contain surveys, censuses, or employ statistical methods? No

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 09/23/2011

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