Information Collection

VA Form 10193 VEPFS Application

IC 222393 under ICR 201607-2900-003 · OMB 2900-0847.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0847 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10193 VA Form 10193 VEPFS Application	Form and Instruction
VA Form 10193 Veterans Employment Pay for Success (VEPFS) Grant Applic PRA APPLICATION VA Form 10193 VEPFS Application v2 20160801.docx www.grants.gov	Form and Instruction

IC Title:

VA Form 10193 VEPFS Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 21.390

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	VA Form 10193	Veterans Employment Pay for Success (VEPFS) Grant Application	PRA APPLICATION VA Form 10193 VEPFS Application v2 20160801.docx	http://www.grants.gov	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: Veteran, Patient, Employee and Volunteer Research and Development Project Records-VA (34VA12)

FR Citation: 40 FR 38095

Number of Respondents: 25

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	2,000	2,000
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.