Survey of Veteran Enrollees' Health and Reliance Upon VA

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-21034G (CATI) Survey of Veteran Enrollees	Form	Modified	Available
2012_Survey Mail Notification Letter.docx	Supplementary Document	Uploaded 2012-12-26	Available
2012_Phone Survey Notification Letter.docx	Supplementary Document	Uploaded 2012-12-26	Available
2012 VHA Methodological Experiments_113012 (2).pdf	Supplementary Document	Uploaded 2012-12-26	Available
Strata 2011_spreadsheet.xlsx	Supplementary Document	Uploaded 2012-12-26	Available
General Background Information on the Survey.docx	Supplementary Document	Uploaded 2012-12-26	Available
2900-0609 VA Security Memo.pdf	Supplementary Document	Uploaded 2010-10-19	Available
2900-0609 justification.docx	Supporting Statement A	Uploaded 2012-12-27	Available
Justification B FINAL_12_12.doc	Supporting Statement B	Uploaded 2012-12-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28855	Survey of Veteran Enrollees' Health and Reliance Upon VA	Form	Modified	(CATI) Survey of Veteran Enrollees

ICR Details

OMB Control No: 2900-0609	ICR Reference No: 201212-2900-013
Status: Historical Active	Previous ICR Reference No: 200902-2900-005
Agency/Subagency: VA	Agency Tracking No: 2900-0609
Title: Survey of Veteran Enrollees' Health and Reliance Upon VA
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: 02/04/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/27/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2016	36 Months From Approved	11/30/2013
Responses	42,080	0	42,080
Time Burden (Hours)	14,728	0	14,400
Cost Burden (Dollars)	0	0	0

---

Abstract: Study of enrollees' health status, income, reliance on VA & interest in Prescription-Only Program will provide information for planning & policy development for actuarial projections of enrollment, utilization, expenditures, mandated annual enrollment reforms, & quantitative & qualitative research.

---

Authorizing Statute(s): PL: Pub.L. 104 - 262 Entirety Name of Law: Veterans Health Care Eligibility Reform Act of 1996,
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 211	11/01/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 50	03/14/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Survey of Veteran Enrollees' Health and Reliance Upon VA	VA Form 10-21034G	(CATI) Survey of Veteran Enrollees

---

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	42,080	42,080	0	0	0	0
Annual Time Burden (Hours)	14,728	14,400	0	0	328	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: The increase in burden was caused by a change in the completion time.

---

Annual Cost to Federal Government: $1,500,000

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]? 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

---

Common Form ICR:  No

---

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: 12/27/2012

---