2018-07140

Supporting Statement for VA Form 21-0845,
Authorization to Disclose Personal Information to a Third Party
OMB #2900-0736
A.

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. Information is requested by this form under the authority of 5 U.S.C.
552a and 38 U.S.C. 5701 as implemented by 38 CFR 1.526(a) and 38 CFR 1.576(b).
This request is for an extension only. No changes made to the collection. The burden
estimate has not changed.
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 21-0845 is used to release information in its custody or control in the following
circumstances: where the individual identifies the information and consents to its use; for the
purpose for which it was collected or a consistent purpose (i.e., a purpose which the
individual might have reasonably expected). By law, VA must have a claimants or
beneficiary’s written permission (an "authorization") to use or give out claim or benefit
information for any purpose that is not contained in VA’s System of Records, 58VA21/22/28
Compensation, Pension, Education and Vocational Rehabilitation and Employment Records.
The claimant or beneficiary may revoke the authorization at any time, except if VA has
already acted based on the claimant’s permission.
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 21-0845 is available on the One-VA Website in a fillable electronic format. VBA
is currently hosting this form on a secure server and does not currently have the technology
in place to allow for the complete submission of the form. Validation edits are 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.

Supporting Statement for VA Form 21-0845,
Authorization to Disclose Personal Information to a Third Party
OMB #2900-0736
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 Form 21-0845 is used to release information in the following circumstances: where the
individual identifies the information and consents to its use; for the purpose for which it was
collected or a consistent purpose (i.e., a purpose which the individual might have reasonably
expected).
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. 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 May 7, 2019, Volume 84,
No. 88, pages 20002 and 20003. No comments were received in response to this notice.

Supporting Statement for VA Form 21-0845,
Authorization to Disclose Personal Information to a Third Party
OMB #2900-0736
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 84 FR 4138 (February 14, 2019).
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:
a. Number of Respondents is estimated at 20,000 per year.
b. Frequency of Response is one time.
c. Annual burden hours are 1,667 hours.
d. The estimated completion time for each form is 5 minutes.
e. The respondent population for VA Form 21-0845 is composed of claimants or
beneficiaries who authorize the VA to disclose information to an individual or
organization. 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 mean hourly wage is $24.98
based on the BLS wage code – “00-0000 All Occupations.” This information was taken
from the following website: https://www.bls.gov/oes/current/oes_nat.htm.

Supporting Statement for VA Form 21-0845,
Authorization to Disclose Personal Information to a Third Party
OMB #2900-0736
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
$41,641.66 (1,667 burden hours x $24.98 per hour).
13. Provide an estimate of the total annual cost burden to respondents or recordkeepers
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.
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.
Estimated Costs to the Federal Government:

Fraction
of Hour

Hourly Rate

Cost Per
Response

Total
Responses

5
3
30
Overhead at 100% Salary

0.50

$15.00

7.500

226,000

$ 1,695,000.00
$ 1,695,000.00

9
3
15
Overhead at 100% Salary

0.25

$22.73

5.683

226,000

$ 1,284,245.00
$ 1,284,245.00

11
3
15
Overhead at 100% Salary

0.25

$27.50

6.875

226,000

$ 1,553,750.00
$ 1,553,750.00

Grade

Step

Burden
Time

Processing / Analyzing Costs
Printing and Production Cost
Total Cost to Government

Total

$ 9,065,990.00
$ 100,733.22
$ 9,166,723.22

Overhead costs are 100% of salary and are same as the wage listed above and the
amounts are included in the total.
Printing and production costs is an approximation of the cost of printing this
information collection per year. (Processing/Analyzing Cost total divided by $90)

Supporting Statement for VA Form 21-0845,
Authorization to Disclose Personal Information to a Third Party
OMB #2900-0736
Note: The hourly wage information above is based on the hourly 2019 General Schedule
(Base) Pay (https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salarytables/pdf/2019/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 withingrade step (3) of each employee represents the average experience of employees within each
grade.
15. Explain the reason for any burden hour changes since the last submission.
The respondent burden has not changed.
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.
The information collection is not for publication or tabulation use.
17. 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.
18. 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.