RIN 2900-AO79 Reimbursement of Certain Medical Expenses for Camp Lejeune Family Members

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-10068c Camp Lejeune Family Member Program Information Update Form	Form and Instruction	New	Available
Form 10-10068b Camp Lejeune Family Member Program Treating Physician Report	Form and Instruction	New	Available
Form 10-10068a Camp Lejeune Family Member Program Claim Form	Form and Instruction	New	Repair queued
Form 10-10068 Camp Lejeune Family Member Program Application	Form and Instruction	New	Available
AO79(IF)-Impact Analysis (6-4-13 f)-VHA-CampLejeune FM.DOCX	Supplementary Document	Uploaded 2014-03-26	Available
Justification A_Camp Lejeune (clean).doc	Supporting Statement A	Uploaded 2014-09-17	Available
Emergency Clearance Request AO79 Camp Lejeune.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2014-03-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
210897	Camp Lejeune Family Member Program Information Update Form	Form and Instruction	New
210896	Camp Lejeune Family Member Program Treating Physician Report	Form and Instruction	New
210895	Camp Lejeune Family Member Program Claim Form	Form and Instruction	New
210894	Camp Lejeune Family Member Program Application	Form and Instruction	New

ICR Details

OMB Control No: 2900-0822	ICR Reference No: 201403-2900-015
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: RIN 2900-AO79 Reimbursement of Certain Medical Expenses for Camp Lejeune Family Members
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 04/28/2014
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/30/2014
	Date Received in OIRA: 03/26/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2015	6 Months From Approved
Responses	21,720	0	0
Time Burden (Hours)	5,838	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Department of Veterans Affairs (VA) promulgates regulations to implement statutory authority to provide reimbursement for hospital care and medical services provided to certain veterans' family members who resided at Camp Lejeune, North Carolina, for at least 30 days during the period beginning on January 1, 1957, and ending on December 31, 1987. Under this rule, VA will reimburse family members for medical expenses incurred as a result of certain illnesses and conditions that may be attributed to exposure to contaminated drinking water at Camp Lejeune during this time period. Reimbursement will be made within the limitations set forth in statute. In order to furnish such care, VA must collect certain information from the family members to ensure that they meet the requirements of the law.

Emergency Justfication: Under 38 U.S.C. 1787, VA is required to furnish hospital care and medical services to the family members of certain veterans who were stationed at Camp Lejeune between 1957 and 1987. In order to furnish such care, VA must collect certain information from the family members to ensure that they meet the requirements of the law. VA cannot furnish the statutorily-mandated hospital care and medical services until the collection of information is approved. The specific hospital care and medical services that VA must provide are for a number of illnesses and conditions connected to exposure to contaminated drinking water while at Camp Lejeune. Many of these conditions are life-threatening and require immediate medical attention. Therefore, VA certifies that the collection of information meets each of the listed criteria.

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Authorizing Statute(s): US Code: 38 USC 1787 Name of Law: Health care of family members of veterans stationed at Camp Lejeune, North Carolina
  

Citations for New Statutory Requirements: US Code: 38 USC 1787 Name of Law: Health care of family members of veterans stationed at Camp Lejeune, North Carolina

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AO79	Final or interim final rulemaking	12 FR 3456	03/28/2014

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Camp Lejeune Family Member Program Application	10-10068	Camp Lejeune Family Member Program Application
Camp Lejeune Family Member Program Claim Form	10-10068a	Camp Lejeune Family Member Program Claim Form
Camp Lejeune Family Member Program Information Update Form	10-10068c	Camp Lejeune Family Member Program Information Update Form
Camp Lejeune Family Member Program Treating Physician Report	10-10068b	Camp Lejeune Family Member Program Treating Physician Report

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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	21,720	0	21,720	0	0	0
Annual Time Burden (Hours)	5,838	0	5,838	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: Due to a new Statue this will be an increase in burden hours.

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Annual Cost to Federal Government: $91,335

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: 03/26/2014

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