2900-NEW, Supporting Statement (4142-4142a)

Supporting Statement for:

2900-NEW

VA Form 21-4142	General Release for Medical Provider Information to the Department of Veterans Affairs (VA)
VA Form 21-4142a	Authorization and Consent to Release Information to the Department of Veterans Affairs

1. JUSTIFICATION:

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

The Department of Veterans Affairs (VA) through its Veterans Benefits Administration (VBA) administers an integrated program of benefits and services, established by law, for veterans, service personnel, and their dependents and/or beneficiaries. Title 38 U.S.C. 5101(a) provides that a specific claim in the form provided by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by the Secretary. VA Form 21-526 is the prescribed form for initial disability claims. VA Form 21-526b is the prescribed form for supplemental disability or ancillary benefit claims. VA Form 21-4142 is used to authorize the disclosure of information to the VA and VA Form 21-4142a is used to gather private provider information of the Veteran to VA.

This is a request for a new control number. VA Forms 21-4142 and 21-4142a were previously approved under control number 2900-0001. They have been separated from this control group so a new control number can be assigned. VA Forms 21-4142 and 21-4142a are being revised to include new standardization data points; to include optical character recognition boxes. VA Form 21-4142a has been further revised to include patient identification information. This addition does not increase the burden.

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 Forms 21-4142 will be used to authorize the disclosure of information to the VA and 21-4142a will be used to gather the necessary information to request medical provider information to the VA.

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.

VA Forms 21-4142 and 21-4142a are available on the One-VA web site in a fillable electronic format. VBA hosts these forms on a secure server and does not currently have the technology in place to allow for the complete submission of the form. Validation edits will be performed to assure data integrity. 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.

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.

Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency which maintains the necessary information, nor is it available from other sources within our Department.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The collection of information does not involve small businesses or entities.

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.

VA Forms 21-4142 will be used to authorize the disclosure of information to the VA and 21-4142a will be used to gather the necessary information to request medical provider information to the VA. Without the information solicited by this form, VA would be unable to determine eligibility, and benefits would not be properly paid.

7. 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 is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.

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 Department notice was published in the Federal Register on June 30, 2017, Volume 82, No. 125, page 30004. No comments were received in response to this notice.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payments or gifts to respondents have been made under this collection of information.

10. Describe any assurance of privacy to the extent permitted by law provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

The records are maintained in the appropriate Privacy Act System of Records identified as “Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28),” published at 74 FR 29275 on June 19, 2009, and last amended at 77 FR 42593 (July 19, 2012).

11. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), 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.

12. Estimate of the hour burden of the collection of information:

1. Number of Respondents is estimated to total 132,400 per year.

   1. 66,200 for VA Form 21-4142

   2. 66,200 for VA form 21-4142a

2. Frequency of Response is one time.

3. Annual burden hours totals 11,033 hours.

   1. 5,516.50 for VA Form 21-4142

   2. 5,516.50 for VA Form 21-4142a

4. The estimated completion time for each form is:

   1. 5 minutes for VA Form 21-4142

   2. 5 minutes for VA Form 21-4142a

5. The respondent population for VA Forms 21-4142 and 21-4142a is composed of individuals who are allowing the VA to gather the necessary information to request medical provider information to the VA. VA 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 $954.40. Assuming a forty (40) hour work week, the mean hourly wage is $23.86 based on the BLS wage code – “00-0000 All Occupations.” This information was taken from the following website: (http://www.bls.gov/oes/current/oes_nat.htm#00-0000, May 2016).

Legally, respondents may not pay a person or business for assistance 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 $263,271.24 (11,034 burden hours x $23.86 per hour).

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).

This submission does not involve any recordkeeping costs.

13. 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.

Estimated Costs to the Federal Government:

Grade	Step	Burden Time	Fraction of Hour	Hourly Rate	Cost Per Response	Total Responses	Total
7	3	30	0.50	$18.07	9.035	132,400	$ 1,196,234.00
Overhead at 100% Salary							$ 1,196,234.00
9	3	30	0.50	$22.11	11.055	132,400	$ 1,463,682.00
Overhead at 100% Salary							$ 1,463,682.00
11	3	15	0.25	$26.75	6.688	132,400	$ 885,425.00
Overhead at 100% Salary							$ 885,425.00
Processing / Analyzing Costs							$ 7,090,682.00
Printing and Production Cost							$ 78,785.36
Total Cost to Government							$ 7,169,467.36

Overhead costs are 100% of salary and are same as the wage listed above and the amounts are included in the total.

Note: The hourly wage information above is based on the hourly 2017 General Schedule (Base) Pay (https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2017/GS_h.pdf ). This rate does not include any locality adjustment as applicable.

The processing time estimates above are based on the actual amount of time employees of each grade level spend to process to completion a claim received on this form. The within-grade step (3) of each employee represents the average experience of employees within each grade.

13. Explain the reason for any burden hour changes since the last submission.

This is a request for a new control number. VA Forms 21-4142 and 21-4142a were previously approved under control number 2900-0001. They have been separated from this control group so a new control number can be assigned. VA Forms 21-4142 and 21-4142a are being revised to include new standardization data points; to include optical character recognition boxes. VA Form 21-4142a has been further revised to include patient identification information. This addition does not increase the burden.

13. 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.

The information collection is not for publication or tabulation use.

13. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

We are not seeking approval to omit the expiration date for OMB approval.

13. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

This submission does not contain any exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

No statistical methods are used in this data collection.