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	Modified	Repair queued
Form 10-10068b Camp Lejeune Family Member Program Treating Physician Report	Form and Instruction	Modified	Available
Form 10-10068a Camp Lejeune Family Member Program Claim Form	Form and Instruction	Modified	Available
Form 10-10068 Camp Lejeune Family Member Program Application	Form and Instruction	Modified	Available
2900-0822 30 day FRN-1.docx	Supplementary Document	Uploaded 2015-05-06	Available
2900-0822 Nonsub change_dates_GO_20141231.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-12-31	Available
AO79(IF)-Impact Analysis (6-4-13 f)-VHA-CampLejeune FM.DOCX	Supplementary Document	Uploaded 2014-03-26	Available
201412-2900-005_Justification A_Camp Lejeune _OMB Comments 2015 (BW edits)_clean 6-26-15.doc	Supporting Statement A	Uploaded 2015-06-26	Repair queued
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	Modified
210896	Camp Lejeune Family Member Program Treating Physician Report	Form and Instruction	Modified
210895	Camp Lejeune Family Member Program Claim Form	Form and Instruction	Modified
210894	Camp Lejeune Family Member Program Application	Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0822	ICR Reference No: 201412-2900-005
Status: Historical Active	Previous ICR Reference No: 201403-2900-015
Agency/Subagency: VA	Agency Tracking No: VHA
Title: Reimbursement of Certain Medical Expenses for Camp Lejeune Family Members
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/09/2015
	Date Received in OIRA: 05/18/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2018	36 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.

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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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 77096	12/23/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 23640	04/28/2015
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 Claim Form	10-10068a	Camp Lejeune Family Member Program Claim Form
Camp Lejeune Family Member Program Treating Physician Report	10-10068b	Camp Lejeune Family Member Program Treating Physician Report
Camp Lejeune Family Member Program Information Update Form	10-10068c	Camp Lejeune Family Member Program Information Update Form
Camp Lejeune Family Member Program Application	10-10068	Camp Lejeune Family Member Program Application

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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	0	0	0	21,720
Annual Time Burden (Hours)	5,838	0	0	0	0	5,838
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: $133,281

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: 05/18/2015

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