Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)

Forms and Documents

Document Name	Status
Form VA Form 21-0779 Request for Nursing Home Information in Connection with Claim for Aid and Attendance Form	Modified
2016-20364, 30-Day FRN, 2900-0652 (21-0779).pdf Supplementary Document	2016-09-27
2900-0652 VAF21-0779 SS.docx Supporting Statement A	2016-09-27
2016-13391, 60-Day FRN, VAF21-0779.pdf Supplementary Document	2016-06-09

IC Document Collections

IC ID	Document Title	Status
28927	Request for Nursing Home Information in Connection with Claim for Aid and Attendance Form	Modified

ICR Details

OMB Control No: 2900-0652	ICR Reference No: 201602-2900-005
Status: Historical Active	Previous ICR Reference No: 201304-2900-024
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/17/2017
	Date Received in OIRA: 09/30/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved	02/28/2017
Responses	61,125	0	50,000
Time Burden (Hours)	10,188	0	8,333
Cost Burden (Dollars)	201,519	0	0

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Abstract: VA Form 21-0779 is used to gather the necessary information to determine eligibility for pension and aid and attendance based on being in a nursing home. This form also requests information on Medicaid status and nursing home care charges, so VA can determine the proper rate of payment.

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Authorizing Statute(s): US Code: 38 USC 1502 Name of Law: Determination with respect to disability
   US Code: 38 USC 1115(1)(E) Name of Law: Aid and attendance
   US Code: 38 USC 1311(c) Name of Law: Dependency and indemnity compensation to a surviving spouse
   US Code: 38 USC 1315(h) Name of Law: Dependency and Indemnity compensation to parents
   US Code: 38 USC 5503 Name of Law: Hospitalized veterans and estates of incompetent institutionalized veterans
   US Code: 38 USC 501(a)(2) Name of Law: Rules and regulations
  

Citations for New Statutory Requirements: None

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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:
	81 FR 109	06/07/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 165	08/25/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Nursing Home Information in Connection with Claim for Aid and Attendance	VA Form 21-0779	Request for Nursing Home Information in Connection with Claim for Aid and Attendance

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ICR Summary 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	61,125	50,000	0	11,125	0	0
Annual Time Burden (Hours)	10,188	8,333	0	1,855	0	0
Annual Cost Burden (Dollars)	201,519	0	0	201,519	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The respondent burden hours per response have not changed (10 minutes or 0.16667 hours). VBA re-evaluated the number of these application forms received per year, and increased the estimated number of responses from 50,000 to 61,125. The evaluation was based on actual claims data contained in VBA’s benefits database.

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Annual Cost to Federal Government: $3,276,856

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: 09/30/2016

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