Justification_Beneficiary Travel Application (v2)

Beneficiary Travel Mileage Reimbursement Application Form
OMB 2900-XXXX
VA Form 10-3542

A. Justification

1. Circumstances Making the Collection of Information Necessary

Through the Beneficiary Travel (BT) program, Veterans Health Administration (VHA) provides mileage reimbursement to qualified Veterans or other claimants (referred to as “claimant” hereafter) who incur expense in traveling to healthcare. Determination criteria for claimant qualification and trip reimbursement are stated in 38 U.S.C. Section 111, and require certain information to be gathered. Claimants may apply verbally or in writing, and the same information is gathered in either instance. This collection of information is necessary to enable the VHA to provide this benefit and appropriately ensure that funds are being paid to the correct claimant. Written information is currently being gathered on an obsolete VA form (VA 3542) that was never submitted for OMB approval.

2. Purpose and Use of the Information Collection

The purpose of the information collection is for beneficiaries to apply for the BT mileage reimbursement benefit in an efficient, convenient and accurate manner. VHA must determine the identity of the claimant, the dates and length of the trip being claimed based on addresses of starting and ending points, , and whether expenses other than mileage are being claimed. The form includes a penalty statement and a statement indicating the claimant has traveled at their own expense and not used Government or cost-free resources for this purpose. The claimant is required to sign the form. The form is used only when the claimant chooses not to apply verbally and is provided for their convenience. Once the information is obtained it is entered into a software program that calculates the mileage and resulting reimbursement.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

The use of the paper form allows claimants to apply for reimbursement indirectly (at remote locations and outside of business hours), but use of information technology will enhance the process. The BT Mileage Reimbursement Application form is expected to be made available to claimants via the internet via self serve kiosks located in VA facilities in 2014. Also planned for the future is a web-based application portal accessible via internet and smart phone that will allow claimants further convenience.

4. Duplication of Information

The form allows claimants to apply for mileage reimbursement for trips unique in time, and only information required to define the unique trip is requested. The average number of trips for which a Veteran submits a claim annually is 8. Some of that information is in VA systems however is used to identify the claimant and establish eligibility for the benefit requested.

5. Reducing the Burden on Small Entities

No small businesses or other small entities are impacted by this information collection.

6. Consequences of Not Conducting Collection

Without the information the BT mileage reimbursement benefit, which is established in law, could not be dispersed. Some claimants would be unable to meet the expense of travel to healthcare which would impact their health and quality of life. Preventative healthcare would be impacted and some claimant’s conditions would worsen, causing them to seek more expensive treatment including emergency care.

7. Special circumstances

There are no special circumstances. The information will be voluntary and will not be used for statistical purposes.

8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The notice of Proposed Information Collection Activity was published in the Federal Register: Vol. 78, No. 115 / Friday, June 14, 2013, Page 36035. VHA received no comments in response to this notice.

b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances, which preclude consultation every three years with representatives of those from whom information is to be obtained.

1. Outside consultation is conducted with the public through the 60- and 30-day Federal Register notices.

2. VA meets with Veteran Service Organizations and public advocacy organizations on a regular basis. The BT mileage reimbursement program is discussed and feedback on any changes is solicited. The form for which approval is requested will replace a obsolete VA form that was never approved by OMB.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

The BT mileage reimbursement program is established in 38 U.S.C. Section 111. The information gathered by use of the form allows for dispersal of the BT mileage benefit, for which the reimbursement rate is currently $.415 per mile traveled or actual cost of travel when using common carrier (public transportation).

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statue, regulation, or agency policy.

Assurances of confidentiality are contained in 38 U.S.C. 5701 and 7332. Respondents are informed that the information collected will become part of the Consolidated Health Record which complies with the Privacy Act of 1974. This is part of the system of records identified as 24VA136 “Patient Medical Record – VA” as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.access.gpo.gov/su_docs/aces/2003_pa.html

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature.

12. Estimate of the hour burden of the collection of information:

1. VTS Questionnaire VA Form 10-3542

Number of respondents is estimated at	1,450,000
Frequency of response is annually	8.0
Number of responses is estimated at	11,600,000
Average estimated response time is	3 min.
Annual burden is estimated at	580,000 hours

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.

This request covers one form.

c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

The cost to the respondents for completing these forms is $13,340,000 (580,000 hours x $23 per hour). We do not require any additional recordkeeping.

13. Provide an estimate of the total annual cost burden to respondents or record keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

a. There is no capital, start-up, operation or maintenance costs.

b. Cost estimates are not expected to vary widely.

c. There are no anticipated capital start-up cost components or requests to provide information.

d. There is no additional cost to respondents

14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

The cost to the Federal Government is estimated at $1,500,000 for processing the Veteran’s in person and paper based claims for Beneficiary Travel reimbursement. The estimate is based on anecdotal reports on use of the obsolete form currently used at VA Medical Centers.

Claim processing	GS 5/5 @ $30/hr x 2 min x 1,450,000 applications / 60 (paper and verbal)	$1,500,000
Printing, Stocking and Distribution of Forms	6,000,000 forms printed annually	$12,000

15. Explain the reason for any program changes or adjustments reported in Items 13 or 14 of OMB 83-I

This is not a new information collection. Rather, implementation of the form will provide Veterans convenient alternative to applying in person for the BT benefit. The BT Program was established in the 1950’s and has been gathering the information necessary to process Veteran’s travel claims either verbally or in writing since that time. VA has not established a specific BT request form but has been using VA Form 3542, “Authorization to Report-Voucher for Mileage Allowance” dated March 1992 for written requests; however, VA recently established that this form is not OMB approved. VA seeks to resolve this issue by obtaining OMB approval for implementation of the BT Mileage Reimbursement Application form which will collect the same information.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

Data collected from the form will be entered into VA information systems during the process of evaluating the claim. Data will later be pulled from the system to report the number of claims, average amount per claim and other data for Medical Centers and VISNs to be used as a tool in management of the benefit including reports to Congress.

17. Display of OMB Approval Date

We are requesting no exemption.

18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

There are no such exceptions.

B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS

No statistical methods are being employed for this data collection.