SUPPORTING STATEMENT FOR
OMB 2900-0376
Agent Orange Registry Work Sheet, VA FORM 10-9009
1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
Public Law 102-585, “Veterans Health Care Act of 1992, Section 703, authorizes the Secretary to provide, upon request, a health examination, consultation, and counseling to a Veteran who is eligible for listing or inclusion in any health-related registry administered by the Secretary that is similar to the Persian Gulf War Veterans Health Registry. Accordingly, the VA provides registry examinations to Veterans who served:
• Vietnam: Military Service in the Republic of Vietnam during the period from January 9, 1962, and ending May 7, 1975, is eligible for VA health care. For purposes of determining eligibility for VA health care, VA presumes herbicide exposure for any Veteran who served in the Republic of Vietnam during the specified period. NOTE: This includes Veterans who served on offshore naval vessels conducting operations on the inland “brown water” rivers and delta areas of Vietnam or who visited the Republic of Vietnam.
• Korea: Military Service at the Demilitarized Zone (DMZ) anytime between April 1, 1968 and August 31, 1971
• Thailand: Working with duty on or near perimeters of military bases in Thailand anytime between February 28, 1961 and May 7, 1975
Plane flying above runway at U-Tapao Air Base; U-Tapao Air Base, Thailand, 1975
US Air Force Veterans who served on Royal Thai Air Force (RTAF) bases at U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, and Don Muang, near the air base perimeter anytime between February 28, 1961 and May 7, 1975.
US Army Veterans who provided perimeter security on RTAF bases in Thailand anytime between February 28, 1961 and May 7, 1975.
US Army Veterans who were stationed on some small Army installations in Thailand anytime between February 28, 1961 and May 7, 1975. However, the Army Veteran must have been a member of a military police (MP) unit or was assigned an MP military occupational specialty whose duty placed him/her at or near the base perimeter
• Active duty personnel who served in a regular USAF unit location where a contaminated C-123 was assigned who had regular contact with the aircraft through flight, ground, or medical duties between 1969 and 1986, and who developed an Agent Orange related disability.
• Reservists who were assigned to flight, ground or medical crew duties at the following locations between 1969 and 1986 and who developed an Agent Orange related disability.
Lockbourne/Rickenbacker Air Force Base in Ohio (906th and 907th Tactical Air Groups or 355th
and 356th Tactical Airlift Squadron)
Westover Air Force Base in Massachusetts (731st Tactical Air Squadron and 74th Aeromedical Evacuation Squadron)
Pittsburgh, Pennsylvania, International Airport (758th Airlift Squadron)
and/or any US Veteran who may have been exposed to dioxin, or other toxic substance in a herbicide or defoliant, during the conduct of, or as a result of, the testing, transporting, or spraying of herbicides and who requests an Agent Orange Registry examination.
The Department of Veterans Affairs (VA), in an on-going effort to maintain an Agent Orange Registry (AOR) developed a reporting format to facilitate the collection of information obtained from the Veteran during the Agent Orange registry examination process.
The Privacy Act Statement will be communicated to the Veteran with a laminated card (to save on paper and if a copy is requested it will be provided. Additionally, the Environmental Health Coordinator will verbally communicate the information to the Veteran.
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.
VA Environmental Health Coordinators obtain demographic data from existing records. The examining physician, Environmental Health (EH) Coordinator (formerly identified as the Agent Orange coordinator)/or other designated personnel obtain the remainder of the information during the Agent Orange registry medical examination process. This is a voluntary examination requested by the Veteran at a time convenient to them and performed at a medical facility or clinic. The information obtained from the Veteran is entered directly onto an electronic VA Agent Orange Form 10-9009, Agent Orange Registry Worksheet (formerly identified as an Agent Orange Registry Code Sheet), via a secured website http://vaww.registries.aac.va.gov by VA personnel and transmitted directly to the Environmental Agents Service (EAS) Agent Orange Registry database located at the Austin Information Technology Center (AITC), Austin, TX Edits are automatically accomplished at the time of entry.
The registry provides a mechanism to catalogue see trends and prominent symptoms associated with possible Agent Orange exposure in the areas of general health, reproductive health and presumptive diagnoses and to communicate with Agent Orange Veterans. VA keeps Veterans informed on research findings or new compensation policies through periodic newsletters. The voluntary, self-selected nature of this registry makes it valuable for health surveillance; however, it is not designed or intended to be a research tool and therefore, the results cannot be generalized to represent all Agent Orange Veterans.
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 describe any consideration of using information technology to reduce burden.
In accordance with the Government Paperwork Elimination Act, VA implemented the electronic submission of these data contained on this worksheet. However, since data is gathered in association with a medical exam, it was determined that publication of the worksheet on the Internet was inappropriate. The information obtained from the Veteran is entered directly by VA personnel onto an electronic worksheet via a secured intranet website http://vaww.registries.aac.va.gov and transmitted directly to the EAS automated Agent Orange Registry database located at the AITC, Austin, TX. Edits are automatically accomplished at the time of entry. To prevent duplication of data, the website is linked to the National Patient Care Database (NPCD) enabling the Environmental Health (EH) Coordinator to populate the worksheet with the needed demographic and service date information.
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.
This interview is needed as the information being collected during the Agent Orange registry examination process is not available from another source. The information is obtained during a focused medical examination reviewing diagnoses or conditions possibly associated with Agent Orange Exposure.
5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.
No small businesses or other small entities are impacted by this information collection.
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.
Collection frequency is based on the self-request by Veterans who may have been exposed to the Agent Orange herbicide for the scheduling of physical examinations. VA would be unable to keep Veterans who have been exposed to Agent Orange informed on research findings, new compensation policies and provide Congress and its constituents with updated summary findings if this information was omitted or collected less frequently.
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. Collection frequency is based on the Veteran’s request for an Agent Orange registry exam. The initial exam and any follow-up examinations are voluntary and performed upon request.
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 Thursday, October 6, 2016, pages 69571- 69572, Volume 81, No. 194.
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.
Public comment will be provided through the 60 and 90-day comment period as announced in the Federal Register.
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.
Describe any assurance of privacy, to the extent provided by law, to respondents and the basis for the assurance in statue, regulation, or agency policy.
Assurances of confidentiality are contained in 38 U.S.C. 5701 and 7332. Respondents are informed that the information collected will become part of the Consolidated Health Record that complies with the Privacy Act of 1974. These worksheets are part of the system of records identified as identified as 24VA10P2 “Patient Medical Record – VA” as set forth in the Compilation of Privacy Act Issuances via online GPO access at: https://www.gpo.gov/fdsys/pkg/FR-2012-10-31/pdf/2012-26801.pdf
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. The medical examination is focused on conditions that may be related to Agent Orange exposure. Use of that information is to offer medical advice and treatment as necessary.
12. Estimate of the hour burden of the collection of information:
a. Annual burden estimate.
We estimate that 20,000 registry examinations will be conducted annually with 30 minutes required per Veteran for a total of 10,000 burden hours. This will decrease over time with the aging of our Vietnam Veteran population. Currently the examinations have averaged 20,000 voluntary requests per year for almost 40 years.
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.
This request covers only one worksheet.
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.
The respondent population for VA Form 10-9009 is for a registry that provides a mechanism to catalogue prominent symptoms, reproductive health, and diagnoses and to communicate with Agent Orange Veterans. VHA 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 (BLS) gathers information on full-time wage and salary workers. According to the latest available BLS data, the median weekly earnings of full-time wage and salary workers are $600.00. Assuming a forty (40) hour work week, the median hourly wage is $14.19.
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. VHA estimates the total cost to all respondents to be $141,900 (10,000 burden hours x $14.19 per hour).
May 2015 National Occupational Employment and Wage Estimates United States:
http://www.bls.gov/oes/current/oes_nat.htm
31-0000 |
major |
3,989,910 |
0.4% |
28.934 |
$13.00 |
$14.19 |
$29,520 |
0.2% |
13. Provide an estimate of the total annual cost burden to respondents or record keepers 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 is no record keeping costs.
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.
The estimated annual cost to the Federal Government is $1,677,220.
EH Coordinator (GS-6/5) at $20.04/hour x 20,000 worksheets x 7 minutes/60 = $46,760
Overhead at 100% of salary = $46,760
EH Clinician Average of $55/hour x 20,000 exams x 30 minutes/60 = $550,000
Overhead at 100% of salary = $550,000
Coder (GS-5/5) at $17.97/hour x 20,000 exams x 10 minutes/60 = $59,600
Overhead at 100% of salary = $550,000
Recurring costs at Austin = $364,500
Overhead costs are 100% of salary and are the same as the wage listed above and the amounts are included in the total.
15. Explain the reason for any program changes or adjustments reported in Items 13 or 14 of OMB 83-I (which would include forms
The adjustments reported in item 14 are a result of hourly pay increases for the Environmental Health Clinician, and VA’s GS staff Coordinator and Coder. The adjusted rates are based on the last scale for federal pay rates within the past 3 years.
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 formally publish the results of the information collected in a regular or recurring format or report. Simple descriptive summaries of the registry may be provided through updates on websites or in newsletters produced by the VA program office.
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 seeks to minimize the cost to itself of collecting, processing and using the information by not displaying or announcing the expiration date. The survey is conducted during a physical examination and inclusion of the expiration date would place an unnecessary burden on the respondent. The information is available upon request.
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 exceptions.
No statistical methods are used in this data collection.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SUPPORTING STATEMENT FOR VA FORM 10-9009 #3 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |