SUPPORTING STATEMENT
Authorization to Disclose Personal Information to a Third Party (VA Form 29-0975)
Justification
Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
This form will be used by the Department of Veterans Affairs Insurance Center (VAIC) to enable a third party to act on behalf of the insured Veteran/beneficiary. Many of our customers are of advanced age or suffer from limiting disabilities and need assistance from a third party to conduct their affairs. The information collected provides an optional service and is not required to receive insurance benefits.
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.
The form will be completed by the insured Veteran or beneficiary, mailed or faxed to the VAIC, and will name individuals or an organization to whom insurance information may be released. The information requested will identify the Veteran/beneficiary and provide a method to verify the identity of the third party.
This form is not yet in use.
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 describe any consideration of using information technology to reduce burden.
The form will be available on the One-VA web site in a fillable electronic format. VBA will host this form on a secure server and does not currently have the technology in place to allow for the complete submission of the form. Validation edits are performed to assure data integrity. Efforts within VA are underway to provide a mechanism to allow the information to be submitted electronically with a recognized signature technology. There currently is no utility process in place that will allow the data submitted on the form to be incorporated with an existing centralized legacy database.
Describe efforts to identify duplication. Show specifically why all similar information already available cannot be used or modified for use for the purposes described in Item 2 above.
The information is not contained in any other VA records. Similar information is not available elsewhere.
If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.
The information does not involve small businesses.
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.
Without the use of this form, a legal Power of Attorney must be executed in order for a third party who is assisting the insured Veteran/beneficiary to access only specific information or to change the mailing address on the insurance record. This increases the burden on the insured Veteran/beneficiary and their third party assistants.
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 special circumstances requiring that the collection of information be conducted in a manner inconsistent with the guidelines in 5 CFR Section 1320.6.
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 sponsor in response to these comments. Specifically address comments received on cost and hour burden.
The department notice was published in the Federal Register on January 19, 2017, Volume 82, Number 12, pages 6729 – 6730.
Explain any decision to provide any payment or gift to respondents.
The information collected is supplied by the respondent. No remuneration is made.
Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statue, regulation, or agency policy.
The information collection conforms to the Privacy Act of 1974 and is subject to the conditions of disclosure contained therein. The records are maintained in the system identified as 36VA29 Veterans and Uniformed Services Personnel Program of U.S. Government Life Insurance – VA” as contained in the Privacy Act Issuances, 2011 Compilation.
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.
Estimate of the hour burden of the collection of information:
Estimate of Information Collection Burden:
a. Number of Respondents: 1200
b. Frequency of Response: On Occasion
c. Annual Burden Hours: 100 hours
d. Estimated Completion Time: 5 minutes
e. The respondent population is composed of Veterans. VBA cannot make further assumptions about the population of respondents because of the variability of factors such as the educational background and wage potential of respondents. Therefore, VBA used general wage data to estimate the respondents’ costs associated with completing the information collection.
The Bureau of Labor Statistics gathers information on full-time wage and salary workers. Accordingly, the median weekly earnings of full-time wage and salary workers is $929.20. Assuming a forty (40) hour work week, the median hourly wage is $23.23 based on the BLS wage code – “00-0000 All Occupations”.
Legally, respondents may not pay a person or business for assistance in completing the information collection and a person or business may not accept payment for assisting a respondent in completing the information collection. Therefore, there are no expected overhead costs for completing the information collection. VBA estimates the total cost to all respondents to be $2323.00 (100 burden hours x $23.23 per hour).
We estimate approximately 1200 forms a year will be received. We arrived at this estimate by reviewing a random sampling of incoming correspondence to determine the percentage of third party requests. We then applied this percentage to the fiscal year average of received correspondence and assumed ¼ of the requests would be replaced by this form.
We also estimate it will take approximately 5 minutes to complete the form. We arrived at this estimate based upon the respondent burden on a similar form used by the VA Regional Offices.
Provide an estimate of the total annual cost burden to respondents or record keepers resulting from the collection of information.
This submission does not involve any record keeping costs.
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.
$1,078.80 Estimated mailing costs (1,200 x 2 minute per form x $15.51/hour (average salary for station mail personnel) plus 1,200 x 38.2 cents each (presort discount)).
$559.20 Estimated cost for collections (1,200 x 2 minutes per x $13.98/hour (average salary of station collections personnel)).
$1,983.00 Estimated cost for processing (1,200 forms x 5 minutes per form x $19.83/hour (average salary for reviewers)).
$60.00 Estimated printing costs (2,000 x $30/1,000 forms).
$3,681.00 Total cost to government.
Explain the reason for any program changes or adjustments reported in Items 13 or 14 of OMB 83-I.
N/A
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.
This information is collected for insurance purposes only and there are no plans for publication.
If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
There is no reason to omit the expiration date for OMB approval.
Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.
There are no exceptions to the certification statement identified in Item 19 of OMB Form 83-1
The Veterans Benefits Administration does not collect information employing statistical methods.
| File Type | application/msword |
| File Title | BO SURVEY |
| Author | issrfore |
| Last Modified By | SYSTEM |
| File Modified | 2017-08-30 |
| File Created | 2017-08-30 |