Airborne Hazards and Open Burn Pit Registry (AHOBPR) Web-accessible Self-Assessment/Questionnaire (VA Form 10-10066)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-10066 AHOBPR Questionnaire - Qarmat Ali Sub-population Follow-up	Form and Instruction	New	Repair queued
Form 10-10066 Airborne Hazard and Open Burn Pit Registry Self-Assessment Questionnaire	Form and Instruction	New	Missing upstream
Form VA Form 10-10066 Airborne Hazards And Open Burn Pit Registry Self-Assessment Questionnaire	Form	Removed	Repair queued
30-day FRN_AHOBPR_published 07252019.pdf	Supplementary Document	Uploaded 2019-08-13	Missing upstream
60-day FRN_AHOBPR_published 05062019.pdf	Supplementary Document	Uploaded 2019-08-13	Missing upstream
Justification Statement Part A_AHOBPR Self Assessment_Renewal_FINAL revised _August 2019.docx	Supporting Statement A	Uploaded 2019-08-13	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
235614	AHOBPR Questionnaire - Qarmat Ali Sub-population Follow-up	Form and Instruction	New
235161	Airborne Hazard and Open Burn Pit Registry Self-Assessment Questionnaire	Form and Instruction	New
210929	Airborne Hazards And Open Burn Pit Registry Self-Assessment Questionnaire	Form	Removed

ICR Details

OMB Control No: 2900-0800	ICR Reference No: 201903-2900-001
Status: Received in OIRA	Previous ICR Reference No: 201401-2900-002
Agency/Subagency: VA	Agency Tracking No: 2900-0800
Title: Airborne Hazards and Open Burn Pit Registry (AHOBPR) Web-accessible Self-Assessment/Questionnaire (VA Form 10-10066)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/13/2019

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	03/31/2017
Responses	50,686	50,000
Time Burden (Hours)	33,447	33,333
Cost Burden (Dollars)	0	0

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Abstract: Public Law 112-260 Section 201, enacted by President Obama on 10 January 2013, required Department of Veterans Affairs (VA) to establish and maintain an “Airborne Hazards and Open Burn Pit Registry (AHOBPR)” no later than one year from enactment. VA launched the AHOBPR in June 2014. There is no sunset date identified in the law. The Secretary of Veterans Affairs may “include any information in such registry that the Secretary of Veterans Affairs determines necessary to ascertain and monitor the health effects of the exposure of members of the Armed Forces to toxic airborne chemicals and fumes caused by open burn pits.” Currently, VA plans to operate the AHOBPR indefinitely, and we request approval to continue administering the questionnaire. Qarmat Ali: This program is a new request for a follow-up information collection for a subset of Veterans impacted by a specific airborne hazard. In the spring and summer of 2003, approximately 700 U.S. Servicemembers may have been impacted by a specific airborne hazard while serving at a water injection plant in Qarmat Ali (QA), Iraq. The Department of Defense (DoD) was unable to determine specific exposure levels near the water treatment facility. In 2010, in response to DoD’s notification, the VA offered no-cost medical evaluations and encouraged the cohort to enroll in a new Qarmat Ali medical surveillance program within the Gulf War Registry. The QA cohort is also eligible to participate in the AHOBPR program due to their deployment to Iraq. As part of the planned 5-year periodic medical follow-up and surveillance program, self-reported information will be collected through the AHOBPR as outlined above. Additional information on the Qarmat Ali water treatment facility can be found at the following link at: https://phc.amedd.army.mil/PHC%20Resource%20Library/QarmatAliWTPChromiumAssessmentMay2010.pdf. Information collected is voluntary and is used to provide outreach and quality health services to AHOBPR participants. Collected data contributes to VA’s ability to understand the potential health effects of the exposure to burn pit emissions and other airborne hazards during deployment, such as particulate matter.

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Authorizing Statute(s): PL: Pub.L. 112 - 260 201 Name of Law: Establishment of Open Burn Pit Registry
  

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:
	84 FR 19829	05/06/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 35930	07/25/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
AHOBPR Questionnaire - Qarmat Ali Sub-population Follow-up	10-10066	AHOBPR Questionnaire - Qarmat Ali Sub-population Follow-up
Airborne Hazards And Open Burn Pit Registry Self-Assessment Questionnaire	VA Form 10-10066	Airborne Hazards And Open Burn Pit Registry Self-Assessment Questionnaire
Airborne Hazard and Open Burn Pit Registry Self-Assessment Questionnaire	10-10066	Airborne Hazards and Open Burn Pit Registry Self-Assessment Questionnaire

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	50,686	50,000	0	50,686	-50,000	0
Annual Time Burden (Hours)	33,447	33,333	0	33,447	-33,333	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: An additional cost burden of ten minutes, per respondent, is added for the approximately 686 Veterans included in the Qarmat Ali Cohort. All registrants included with this subset cohort also are eligible for the AHOBPR.

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Annual Cost to Federal Government: $1,100,000

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? No

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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: 08/13/2019

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