2900-0205 justification 20150826

SUPPORTING STATEMENT FOR 2900-0205, APPLICATIONS AND APPRAISALS FOR EMPLOYMENT FOR TITLE 38 POSITIONS AND TRAINEES

VA FORMS OF THE 10-2850 SERIES AND THE FL 10-431 SERIES

EXPIRATION DATE XX/XX/XXXX

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

VA Forms 10-2850, 2850a and10-2850c are applications designed specifically to elicit appropriate information about each candidate's qualifications for employment with Department of Veterans Affairs (VA) as well as educational and experience. To assure that a full evaluation of each candidate's credentials can be made prior to employment, the forms require disclosure of details about all licenses ever held, Drug Enforcement Administration certification, board certification, clinical privileges, revoked certification or registration, liability insurance history, and involvement in malpractice proceedings. VA Form 10-2850b, Application for Residents has been replaced with VA Form 10-2850d, Applications for Health Professions Trainees. The 10-2850d form is used by all health professions trainees, including residents.

The collection of this information is authorized by Title 38, United States Code (U.S.C.) 7403, (Veterans’ Benefits), which provides that appointments of Title 38 employees will be made only after qualifications have been satisfactorily verified in accordance with regulations prescribed by the Secretary. Occupations listed in 38 U.S.C. 7401(1) and 7401(3) (Appointments in Veterans Health Administration), are appointed at a grade and step rate or an assignment based on careful evaluation of their education and experience.

Under authority of 38 U.S.C. Chapter 73, residents are appointed at a postgraduate level, commensurate with their education and professional experience. Title 38 United States Code (U.S.C.), Part V, chapter 73, subchapter 1, subsection 7302 (Functions of Veterans Health Administration: health-care personnel education and training programs) mandates that Veterans Health Administration (VHA) assist in the training of health professionals for its own needs and for those of the nation.

All health professions trainees must provide information concerning their background, training and education as well as previously held licenses/registrations to meet the new security and screening requirements. The authority of the Department of Health and Human Services (HHS) Office of Inspector General (OIG) to exclude certain individuals and entities from all federal healthcare programs was expanded by Section 4331(c) of the Balanced Budget Act of 1997, Public Law 105-33, amended sections 1128(a) and B (b) of the Social Security Act. The law requires that all federal healthcare programs ensure that no excluded individual or entity is receiving payment including salary and wages from any federal healthcare program for services furnished on or after the date of the OIG exclusion. Individuals who are affected include all persons appointed to title 5 and title 38 positions as well as through contracts that will be funded with federal healthcare program funds. This includes, but is not limited to appointments to positions as full time, part time, intermittent, permanent, and temporary, term, and fee basis.

FL 10-341a is the pre-employment reference form used to elicit information concerning the prior education and/or performance of the Title 38 applicant. Information provided is used to determine eligibility for employment and the appropriate grade and step rate or assignment.

VA Form 10-2850d is an application designed specifically to elicit appropriate information from medical residents, health professions trainees and students training appointment. VHA conducts education and training programs accomplished through partnerships with affiliated academic institutions and through VA’s sponsored programs. Qualified health care professionals with appropriate credentials and privileges provide the supervision of trainees. The process of progressive responsibility in the clinical environment is the underlying educational principle for all medical and professional education, regardless of specialty or discipline.

Form Letter (FL) 10-341b, Trainee Qualification and Credentials Verification Letter (TQCVL), is completed by the program directors of the affiliated training programs. This letter confirms that the information listed has been verified by the sponsoring entity for the trainees listed and confirms that the trainee is enrolled in the designated training program.

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

Individuals applying for Title 38 positions must complete one of the following: VA Forms 10-2850 and 2850a through c. VA sends FL 10-341a to the educational institutions, organizations and individuals indicated by the applicant on the employment application form. The application forms are reviewed by field station officials, including Medical Center Directors, Chiefs of Staff, Human Resources Management Officers or designees and members of Professional Standards Boards (Board of Peers). These individuals ensure that the applicants meet administrative and regulatory requirements for VA employment, and recommend appointment grade and step rate or assignment based on the individual's qualifications. If the information were not collected on these applications forms and the Form Letter, qualifications could not be assessed.

All health professions trainees will be assessed against any screening results that indicate a history of adverse licensure action, malpractice claims, action against hospital privileges, or other adverse actions that may warrant a more comprehensive review. The review evaluates any identified issues and VA officials may need to obtain additional information from the applicant in order to determine whether the individual will be appointed or denied the appointment. These screens are conducted at the time of initial training appointment and at the time of change from one training program to another. These forms will assist in screening applicants against the Health Integrity and Protection Data Bank (HIPDB) and the List of Exclusions is maintained by Health and Human Services (HHS) Office of Inspector General (OIG) on the List of Excluded Individuals and Entities (LEIE) for health care-related criminal convictions, civil judgments, and other adjudicated actions as specified in regulation.

In addition, all licensed health professional as well as trainees who have or had a previously held license, certification, registration, or Drug Enforcement Agency (DEA) registration must be screened against the National Practitioner Data Bank (NPDB), and/or the (State License Board) SLB databases and/or national certification agencies as appropriate.

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 described any consideration of using information technology to reduce burden.

VA uses the Web site http://www.vacareers.com as a portal for applicants to seek information regarding Physician, Nurse and Other Allied Health Occupation employment at the 163 medical centers across the country. Interested applicants can log onto the applications system Web site, look through the job listings provided by the medical centers, and either complete the application on-line or download a *.pdf version of the form fill it out, and mail it.

The *.pdf version of these forms as well as FL 10-341a are available on http://vaww.va.gov/forms/medical/searchlist.asp. All of these forms are in a print and fill mode. To meet the requirements of the Government Paperwork Elimination Act (GPEA) VA is currently conducting a cost benefits and risk analysis studies on these forms to determine if more action is warranted.

The *.pdf version of VA Form 10-2850d is available on http://vaww.va.gov/forms/medical/searchlist.asp. All forms are in a print and fill mode. The trainee information may be entered electronically by the individual trainees.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

For the VA Form 10-2850 series, there is no other source of applicant data that is accessible to management and human resources officials charged with making employment determinations. The Credentialing data collection verifies from the primary source such information required by the Joint Commission on Accreditation of Healthcare Organizations as the credentialing organization, educational institution, hospital, Federal, state and local governments, licensing board and the National Practitioner Database.

VA Form 10-2850d is an application specific to students, trainees and residents appointed under Title 38. There is no other source specific to students, trainees and interns applicants that are accessible to VA management and personnel officials charged with making appointment determinations. The VA Form 10-2850d and VA Letter 10-341b will enable VA to be compliant with key screening requirements for trainees with less of a burden on trainees and VA officials responsible for the screening process. Only trainees that meet established qualifications and security requirements will be appointed to VA.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

Small businesses are involved only in responding to Form Letters 10-341a and b. Every effort has been made to minimize the burden. Most questions have been phrased so that the respondent simply checks the appropriate answer.

The schools and colleges that send students for clinical training at VA will be required to complete the FL 10-341b Trainee Qualification and Credentials Verification Letter (TQCVL) on all students. These institutions will able to have the option to complete an FL 10-341b for more than one student. The FL 10-341b confirms that the information listed concerning the status of the student has been verified by the sponsoring entity/school. Although an individual form letter can be prepared for each individual trainee, VA allows and encourages attaching a listing of all individuals certified. This significantly reduces the burden on respondents.

6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

Title 38 U.S.C. 7403 provides that appointments of Title 38 individuals will be made only after qualifications have been satisfactorily established in accordance with regulations prescribed by the Secretary. If the information were not collected, qualifications of applicants or trainees could not be assessed and appointments could not be made to VA Medical Centers. The information must be collected in order to meet screening requirements.

The collection is handled on a one-time basis at each medical center to which a Title 38 candidate applies through a single submission for a position. FL’s 10-341a are used only once for a former supervisor or employer identified by the applicant. The FL’s 10-341a are also sent to every education institution listed by the applicant for a position to verify completion of degree requirements. The FL 10-341b is completed for each year of training. No further reduction is feasible if the agency is to continue employing quality health care professionals and providing clinical training for VA and the Nation as required by statue.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

There are no such special circumstances.

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 on February 19, 2015, at pages 8951-8952. VA 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.

These forms are routinely reviewed to assure that all elements essential for hospital accreditation and credential verification are included. This assures the safety requirements of VA patients are adequately addressed. Comments of candidates for VA employment about these application forms are considered on a continuing basis. Outside consultation is conducted with the public through the 60- and 30-day Federal Register notices.

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

No payment or gift is provided to respondents.

10. Describe any assurance of privacy, to the extent permitted by law, provided to respondents and the basis for the assurance in statue, regulation, or agency policy.

The Privacy Act Notice on these forms indicates that information is requested under Title 38, (U.S.C.). Information provided may be released by the Agency under certain circumstances described in the Notice. Records are maintained in the system identified as "Applicants for Employment under Title 38, U.S.C.-VA" (02VA135), 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:

a. Total annual burden hours are estimated at 139,016 hours.

Form	Respondents	Frequency	Annual Responses	Min.	Annual Burden Hours
10-2850	14,900	1	14,900	30	7,450
10-2850a	59,598	1	59,598	30	29,799
10-2850c	19,866	1	19,866	30	9,933
FL 10-341a	50,820	1	50,820	30	25,410
10-2850d	120,771	1	120,771	30	60,386
FL 10-341b	120,771	1	120,771	3	6,038
TOTAL 386,726					139,016

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.

FL 10-341b can be used by educational institution to list multiple trainees on a single form, and are encouraged to do so. Therefore the total number of actual FL 10-341b forms completed will be significantly less than the number shown in the table above. The number shown is the number of trainees that would be entered onto the form. The time in minutes shown for this form represents the entry of each individual trainee, plus additional processing of the entire 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.

Annualized cost to respondents is estimated at $4,585,846. VA does not require any additional recordkeeping. The specific breakdown is summarized below:

Form No.	Burden Hours	Cost per Hour	Total
10-2850	7,450	$83	$618,350
10-2850a	29,799	$38	$1,132,362
10-2850c	9,933	$18	$178,794
FL 10-341a	25,410	$38	$965,580
10-2850d	60,386	$20	$1,207,720
FL 10-341b	6,038	$80	$483,040
TOTAL			$4,585,846

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers 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. The only cost is that for the time of the respondent.

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

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.

Cost to the Federal Government is estimated at $19,420,178:

10-2850	$1,401,658
10-2850a	$2,863,004
10-2850c	$995,901
FL 10-341a	6,178,845
10-2850d	$7,569.351
FL 10-341b	$411,419.
TOTAL	$19,420,178

Key to Interpreting Cost Data
COS	Chief of Staff	$89/hour
SC	Service Chief	$84/hour
P/D	Physician/Dentist	$75/hour
SHS	Senior House Staff - Resident or Intern	$24/hour
RN	Nurse, Intermediate Grade	$38/hour
P/VT	Physical/Vocational Therapist, EFDA, Physicians Assistant	$28/hour
LPN/LVN	Licensed Practical/Vocational Nurse	$17/hour
PMS	Personnel Management Specialist (GS 11/4)	$30/hour
MD PSB	MD Professional Standards Board - COS and 2 SC	$257/hour
RN PSB	Nursing Standards Board – 3 Intermediate Grade Nurses	$114/hour
RN PSB	House Staff Review Committee - COS, 2 SC & 2 SHS	$305/hour
LPN/LVN SB	LPN/LVN Standards Board - 2 RN and LPN	$93/hour
OSB	Other Standards Board – 2 P/D and P/VT	$178/hour
	Clerical (GS 4/4)	$15/hr

a. Cost for VA Form 10-2850 is estimated at $1,401,658.

Processing:	14,900 apps. x 20 min x $ 89/hr review by COS		$442,033
	14,900 apps. x 15 min x $257/hr review by MD PSB		$957,325
Printing/Distribution			$2,300

b. Cost for VA Form 10-2850a is estimated to be $2,863,004.

Processing:	59,598 applications x 20 min x $114/hour for RN PSB		$2,264.724
	59,598 applications x 20 min x $30/hour review by PMS		$595,980
Printing/Distribution			$2,300

c. Cost for VA Form 10-2850c is estimated to be $995,901.

Processing:	13,545 app’s x 20 min x $93/hour for LPN/LVN SB		$419,895
	6,321 applications x 20 min x $178/hour for OSB		$375,046
	19,866 applications x 20 min x $30/hour review by PMS		$198,660
Printing/Distribution			$2,300

d. Cost for VA Form Letter 10-341a is estimated to be $6,182,403.

Processing:	Clerical	=	50,820 x 1.5 min x $15/hour		=	$19,057
	PMS	=	50,820 x 3 min x $30/hour		=	$76,230
	MD PSB	=	15,609x 15 min x $257/hour		=	$1,002,878
	RN PSB	=	62,436 x 15 min x $114/hour		=	$1,779,426
	HSRC	=	33,299 x 15 min x $305/hour		=	$2,539,049
	LPN/LVN SB	=	14,190 x 15 min x $93/hour		=	$329,917
	OSB	=	8,041 x 15 min x $178/hour		=	$357,824
Printing/Distribution						$2,300
Postage	50,820 x $0.49 outgoing					$24,902
	50,820 x $1.00 return					$50,820

e. Cost for VA Form 10-2850d is estimated to be $7,569.351.

Processing:	41,223 applications x 30 min x $305/hr for review by HSRC		$6,286,508
	27,275 applications x 20 min x $38/hr for RN		$345,483
	93,496 applications x 20 min x $30/hr review by PMS		$934,960
Printing/Distribution			$2,400

f. Cost for all names submitted on the VA Form Letter 10-341b is estimated to be $411,419.

Processing:	120,771 applications x 1.5 min. x $15/hr-processing by clerk	$45,289
	120,771 applications x 3 min. x $30/hr for PMS	$181,157
	120,771 applications x 1 min. x $89/hr for PMS	$179,143
Printing/Distribution		$2,400
Postage	7,000 individual letters x $0.49 outgoing postage	$3,430

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

The decrease in burden hours is a result of decreased applications for VA Form 10-2850d, and
FL 10-341b.

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.

There are no plans to publish the results of the information collected.

17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

VA does not seek to omit the expiration date.

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 used in this data collection.

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