Information Collection

VA Meds by Mail Order Form

IC 214210 under ICR 201412-2900-007 · OMB 2900-0832.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10068 VA Meds by Mail Order Form	Form and Instruction
10-10068 VA meds by mail order form Final Draft CLFM Meds by Mail Form.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10068	VA meds by mail order form	Final Draft CLFM Meds by Mail Form.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 110,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	220,000	220,000
Annual IC Time Burden (Hours)	18,333	18,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.