Joint Application for Comprehensive Assistance and Support Services for Family Caregivers, VA Form 10-10CG

Forms and Documents

Document Name	Status
Form VA Form 10-10CG Application for Comprehensive Assistance for Family Caregivers Program Form and Instruction	Modified
30-day FedRegNotice_PRA 2900-0768_VA Form 10-10CG_published_08152019.pdf Supplementary Document	2019-10-22
60-day FedRegNotice_PRA 2900-0768_VA Form 10-10CG_published_05222019.pdf Supplementary Document	2019-10-22
Prog of Comp Assistance to Family Caregivers_10-10CG_Supp Stmnt A_2900-0768_revised Final_Oct 2019.docx Supporting Statement A	2019-10-22

IC Document Collections

IC ID	Document Title	Status
197562	Application for Comprehensive Assistance for Family Caregivers Program Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0768	ICR Reference No: 201903-2900-033
Status: Historical Active	Previous ICR Reference No: 201408-2900-016
Agency/Subagency: VA	Agency Tracking No: 2900-0768
Title: Joint Application for Comprehensive Assistance and Support Services for Family Caregivers, VA Form 10-10CG
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/03/2020
	Date Received in OIRA: 01/28/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2021	36 Months From Approved
Responses	16,500	0	0
Time Burden (Hours)	4,125	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Public Law (P.L.) 111-163, Caregivers and Veterans Omnibus Health Services Act of 2010 amended title 38 United States Code Chapter 17 by adding a new section, 1720G, “Assistance and Support Services for Caregivers”. Section 1720G requires the Department of Veterans Affairs (VA) to develop a Program of Comprehensive Assistance for Family Caregivers and Support Services. Under the law, primary family caregivers may be eligible to receive a stipend, access to health care coverage, mental health counseling, comprehensive caregiver education and training and expanded respite services. Caregivers may also be eligible for travel benefits when they accompany the Veteran for care or attending training. In order to administer these benefits to caregivers, it is necessary that the VA receive information about the nature of benefit being sought and the persons who will be serving as caregivers and receiving benefits. This form collects necessary information from applicants for the Comprehensive Assistance and Support Services for Family Caregivers Program.

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Authorizing Statute(s): PL: Pub.L. 111 - 163 1720G Name of Law: Caregivers and Veterans Omnibus Health Services Act of 2010
  

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 23640	05/22/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 41815	08/15/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Application for Comprehensive Assistance for Family Caregivers Program	VA Form 10-10CG	Application for Comprehensive Assistance for Family Caregivers Program

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ICR Summary 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	16,500	0	0	11,500	0	5,000
Annual Time Burden (Hours)	4,125	0	0	2,875	0	1,250
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: The prior 5,000 data point was the estimated number of applications anticipated for the initial application. Since that time, the program office has received tens of thousands of applications. Over the past eight (8) years since the program has been in existence, the program office has determined that 16,500 would be a fair estimate of continued future applications.

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Annual Cost to Federal Government: $116,500

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? 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: 01/28/2020

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