Exam for Housebound Status or Permanent Need for Regular Aid and Attendance (VA Form 21-2680)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 21-2680 Exam for Housebound Status or Permanent Need for Regular Aid and Attendance	Form	Modified	Available
SuppStmt, 21-2680 (7-30-14).docx	Supporting Statement A	Uploaded 2014-07-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
185651	Exam for Housebound Status or Permanent Need for Regular Aid and Attendance	Form	Modified

ICR Details

OMB Control No: 2900-0721	ICR Reference No: 201406-2900-014
Status: Historical Inactive	Previous ICR Reference No: 201107-2900-023
Agency/Subagency: VA	Agency Tracking No: 2900-0721 VBA-COMP-
Title: Exam for Housebound Status or Permanent Need for Regular Aid and Attendance (VA Form 21-2680)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 08/26/2014
	Date Received in OIRA: 07/30/2014
Terms of Clearance: VA has requested to withdraw this information collection request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2015	36 Months From Approved	05/31/2015
Responses	14,000	0	14,000
Time Burden (Hours)	7,000	0	7,000
Cost Burden (Dollars)	0	0	0

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Abstract: This form will be used to gather medical information on behalf of beneficiaries or claimants who are requesting the aid and attendance or housebound benefit and who receive treatment from private doctors or physicians.

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Authorizing Statute(s): US Code: 38 USC 1521(d) Name of Law: Veterans of a period of war
   US Code: 38 USC 1521(e) Name of Law: Veterans of a period of war
   US Code: 38 USC 1114 Name of Law: Rates of wartime disability compensation
   US Code: 38 USC 1115(1)(e) Name of Law: Additional compensation for dependents
   US Code: 38 USC 1541(d) Name of Law: Surviving spouses of veterans of a period of war
   US Code: 38 USC 1541(e) Name of Law: Surviving spouses of veterans of a period of war
   US Code: 38 USC 1311(d) Name of Law: Dependency and indemnity compensation to a surviving spouse
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AO81	Proposed rulemaking	78 FR 211	10/31/2013

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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: 1

table that charts list of burden

IC Title	Form No.	Form Name
Exam for Housebound Status or Permanent Need for Regular Aid and Attendance	VA Form 21-2680	Examination for Housebound Status or Permanent Need for Regular Aid and Attendance

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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: $641,624

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: 07/30/2014

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