2900-0080 Justification_Reinstatement_Updated BLS_050418

SUPPORTING STATEMENT FOR

FUNERAL ARRANGEMENTS

(VA FORM 10-2065)

2900-0080

A. JUSTIFICATION

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

VA facilities use VA Form 10-2065, Funeral Arrangements, to initiate, authorize and document expenditures relating to burial benefits proscribed in 38 U.S.C. Chapter 23, Burial Benefits and Chapter 24, National Cemeteries and Memorials.

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 Form 10-2065 is part of the Decedent Affairs Package. The form is completed during the interview with relatives of the deceased, and identifies the funeral home to which the remains are to be released. The family signs the form designating that it reflects their wishes. It is used as a control document when VA is requested to arrange for the transportation of the deceased from the place of death to the place of burial, and/or when burial is requested in a National Cemetery.

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 Form 10-2065 is currently a fillable PDF form on the VA Forms and Publications website. VA Form 10-2065 requires a next of kin signature. Management officials have reviewed the form to assure that all the information sought is essential. Improved information technology will not decrease the burden on the public in the use of VA Form 10-2065.

4. Describe effort 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.

There is no data available that can be modified for this purpose. The form is an individual entity and is required for benefit and payment authorization.

5. If the collection of information impacts small businesses or other small entities (Item 5 of OMB form 83-1) describe any methods used to minimize burden.

Since the VA Form 10-2065 is an application for individual benefits, no small businesses or other small entities are impacted by the 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.

If the information on VA Form 10-2065 were not collected, VA’s ability to dispose of the remains of deceased Veterans would be seriously hampered. This data cannot be collected less frequently because it is collected upon the Veteran’s death.

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 are no such special circumstances.

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 11/15/2017 (Vol. 82, FR 529701, pages 52970-52971). We received no comments in response to this notice.

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.

No outside consultations, other than the request for the 30- and 60-day public comment in the Federal Register, were made as only essential information is solicited. Responses to the questions on these forms are considered standard business practice.

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.

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.

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 forms are part of the system of records identified as 24VA19 “Patient Medical Record – VA” as set forth in the Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html.

11. 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 sensitive questions involved in this data collection.

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

a. Based on past experience, we make the following estimate of the total burden:

Respondent Burden
VA Form 10-2065	22,213 responses	x	10 minutes	=	3,702 hours
TOTAL				=	3,702 hours

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.

This request covers one form. See above.

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.

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 $90,106.68 (3,702 burden hours x $24.34 per hour).

May 2017 National Occupational Employment and Wage Estimates United States:

https://www.bls.gov/oes/current/oes_nat.htm

13. Provide an estimate of the total annual cost burden to respondents or recordkeeping resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

There is no additional record keeping.

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.

a. The estimated annual cost to the Federal Government of VA Form 10-2065 is $ 60,160.

Printing and Distribution		=	$5.000
22,213 claims	Salary $14.90 (GS 5/5) x 22,213 claims	=	55,160
No additional costs			0
	Total		$60,160

15. Explain the reason for any program changes or adjustments reported in Items 13 or 14.

There is no program change:

1. VA Form 10-2511: Applicant signature is not collected on VA Form 10-2511 when processing payment for ambulance or other hired vehicle for transportation of beneficiaries. For internal use only. No respondent burden hours apply.

2. VA Form 10-2065: Government burial allowance has increased from $300 to $700. In the block under the 'REMARKS" block both "b" and "c" indicate an allowance of $300 - this must be changed to $700.

3. VA Form 10-583: The form is no longer utilized. Health care billing forms CMS 1500/1450 have replaced form VA Form 10-583. No respondent burden hours apply.

4. VA Form 10-7078: This form is for internal VA medical center staff use, only. No respondent burden hours apply.

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 publish the information collected on any of the forms.

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 the expiration date. We seek an exemption that waives the displaying of the expiration. These are on-going requirement and there is a continuing and reoccurring need for this information collection.

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.

b. Collection of Information Employing Statistical Methods.

This collection of information does not employ statistical methods.

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