Survey of Veteran Enrollees' Health and Reliance Upon VA

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-21034G Survey of Veteran Enrollees w/VE Questions	Form and Instruction	Modified	Available
Justification A 2018 OMB Clearance_Updated FRN_101618.docx	Supporting Statement A	Uploaded 2018-10-16	Available
30 Day FRN - Published.pdf	Supplementary Document	Uploaded 2018-10-16	Available
60 Day FRN - Published.pdf	Supplementary Document	Uploaded 2018-09-18	Available
VA_Enrollee_Postal reminder (003).pdf	Supplementary Document	Uploaded 2018-07-03	Available
VA_Enrollee_Invite Letter_and FAQs 13 Feb (003).pdf	Supplementary Document	Uploaded 2018-07-03	Available
VA_Enrollee_Follow up Letter_with paper survey (003).pdf	Supplementary Document	Uploaded 2018-07-03	Available
SoE 2019_survey changes.docx	Supplementary Document	Uploaded 2018-07-03	Available
Copy of strata_pop_counts_SoE2017.xlsx	Supplementary Document	Uploaded 2018-07-03	Available
2017_Survey_Veteran_Enrollees_Methods Report.pdf	Supplementary Document	Uploaded 2018-07-03	Available
Justification_B_SOE 2018 OMB Clearance.doc	Supporting Statement B	Uploaded 2018-07-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28855	Survey of Veteran Enrollees' Health and Reliance Upon VA	Form and Instruction	Modified	Survey of Veteran Enrollees w/VE Questions

ICR Details

OMB Control No: 2900-0609	ICR Reference No: 201807-2900-002
Status: Historical Active	Previous ICR Reference No: 201601-2900-011
Agency/Subagency: VA	Agency Tracking No: 2900-0609
Title: Survey of Veteran Enrollees' Health and Reliance Upon VA
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/06/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/16/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2022	36 Months From Approved	03/31/2019
Responses	42,000	0	42,000
Time Burden (Hours)	14,000	0	14,000
Cost Burden (Dollars)	0	0	0

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Abstract: Study of enrollees' health status, income, reliance on VA & interest in Prescription-Only Program will provide information for planning & policy development for actuarial projections of enrollment, utilization, expenditures, mandated annual enrollment reforms, & quantitative & qualitative research.

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Authorizing Statute(s): PL: Pub.L. 104 - 262 Entirety Name of Law: Veterans Health Care Eligibility Reform Act of 1996,
  

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:
	83 FR 32953	07/16/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 52303	10/16/2018
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
Survey of Veteran Enrollees' Health and Reliance Upon VA	10-21034G	Survey of Veteran Enrollees w/VE Questions

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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	42,000	42,000	0	0	0	0
Annual Time Burden (Hours)	14,000	14,000	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: $1,000,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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.     No

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.     No

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: 10/16/2018

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