Durable Power of Attorney for Health Care and Living Will, VA Advance Directive

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-0137 Durable Power of Attorney for Health Care and Living Will, VA Advance Directive	Form and Instruction	Unchanged	Available
2900-0556_White Paper-Advance Directive-Spanish-English_12 19 16.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-03-07	Available
2900-0556_White Paper-Advance Directive-12 19 16.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-03-07	Available
Supporting Statement A 2900-0556_VA Form 10-0137_8.23.17.docx	Supporting Statement A	Uploaded 2017-08-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28738	Durable Power of Attorney for Health Care and Living Will, VA Advance Directive	Form and Instruction	Unchanged

ICR Details

OMB Control No: 2900-0556	ICR Reference No: 201704-2900-012
Status: Historical Active	Previous ICR Reference No: 201703-2900-007
Agency/Subagency: VA	Agency Tracking No: 2900-0556
Title: Durable Power of Attorney for Health Care and Living Will, VA Advance Directive
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/13/2017
	Date Received in OIRA: 10/31/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2020	36 Months From Approved	12/31/2017
Responses	343,622	0	343,622
Time Burden (Hours)	171,811	0	171,811
Cost Burden (Dollars)	0	0	0

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Abstract: The form allows VA patients to give specific instructions about their treatment preferences in the event they are no longer competent or able to verbally express these instructions.

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Authorizing Statute(s): US Code: 38 USC 7331 Name of Law: Informed consent
  

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:
	82 FR 37167	08/08/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 48747	10/19/2017
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Durable Power of Attorney for Health Care and Living Will, VA Advance Directive	10-0137, 10-0137	VA Advance Directive - Durable Power of Attorney for Health Care and Living Will ,   VA Advance Directive - Durable Power of Attorney for Health Care and Living Will - Spanish_English

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ICR Summary of Burden

table that charts list 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	343,622	343,622	0	0	0	0
Annual Time Burden (Hours)	171,811	171,811	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $6,379,342

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 10/31/2017

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