Application for Health Professions Trainees - VA Form 10-2850D

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-2850 Applications & Appraisals for Employment for Title 38 Positions and Trainees	Form and Instruction	Removed	Available
Form 10-2850D Application for Health Professions Trainees - VA Form 2850D	Form and Instruction	New	Available
30-day FRN_VA Form 10-2850D_published_07182019.pdf	Supplementary Document	Uploaded 2019-08-13	Available
60-day FRN_VA Form 10-2850D_published_05062019.pdf	Supplementary Document	Uploaded 2019-08-13	Available
Justification Statement A_VA Form 10-2850D_FINAL revised_August 2019.docx	Supporting Statement A	Uploaded 2019-08-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28443	Applications & Appraisals for Employment for Title 38 Positions and Trainees	Form and Instruction	Removed
235698	Application for Health Professions Trainees - VA Form 2850D	Form and Instruction	New

ICR Details

OMB Control No: 2900-0205	ICR Reference No: 201904-2900-002
Status: Active	Previous ICR Reference No: 201502-2900-007
Agency/Subagency: VA	Agency Tracking No: 2900-0205
Title: Application for Health Professions Trainees - VA Form 10-2850D
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/10/2019
	Date Received in OIRA: 08/13/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2022	36 Months From Approved	09/30/2018
Responses	121,000	0	386,726
Time Burden (Hours)	60,500	0	139,016
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 10-2850D, Application for Health Professions Trainees, is designed specifically to elicit appropriate information about qualifications for each trainee participating in accredited educational programs with the Department of Veterans Affairs (VA). The 10-2850D form is used by all health professions trainees, including physician and dentist residents. The collection of this information is authorized by 38 U.S.C. 7403, (Veterans’ Benefits), which provides that appointments of Title 38 employees will be made only after qualifications have been satisfactorily verified in accordance with regulations prescribed by the Secretary. Occupations listed in 38 U.S.C. 7401(1) and 7401(3) (Appointments in Veterans Health Administration), are appointed at a grade and step rate, or an assignment based on careful evaluation of their education and experience. The VA Form 10-2850D application will collect information from health professions trainees prior to VA appointment. All health professions trainees must provide information concerning their background, training, education, degrees, licensure, registrations, and other vital information to ensure appropriate qualifications for VA assignment.

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Authorizing Statute(s): US Code: 38 USC 7401 (1),(3) Name of Law: Appointments in Veterans Health Administration
   US Code: 38 USC 7403 Name of Law: Veterans Benefits - Period of appointments; promotions
   US Code: 38 USC 7302 - Part V, Chapter 73 Name of Law: Healthcare Personnel Education and Training Program
  

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 19830	05/06/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 34476	07/18/2019
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
Applications & Appraisals for Employment for Title 38 Positions and Trainees	VA FL 10-341(b), VA Form 10-2850a, VA Form 10-2850d, VA FL 10-341(a), VA Form 10-2850, VA Form 10-2850C	APPLICATION FOR PHYSICIANS, DENTISTS, PODIATRISTS, OPTOMETRISTS AND CHIROPRACTORS ,   APPLICATION FOR ASSOCIATED HEALTH OCCUPATIONS ,   Application for Health Professions Trainees ,   Employment Reference for Title 38 Employee ,   Trainee Qualification and Credentials Verification Letter (TQCVL) ,   APPLICATION FOR NURSES AND NURSE ANESTHETISTS
Application for Health Professions Trainees - VA Form 2850D	10-2850D	VA Form 10-2850D - Application for Health Professions Trainees

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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	121,000	386,726	0	121,000	-386,726	0
Annual Time Burden (Hours)	60,500	139,016	0	60,500	-139,016	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: VA Form 10-2850D is an application specific to health professions trainees appointed under Title 38. There is no other source specific to health professions trainees that are accessible to VA management and personnel officials charged with making appointment determinations. The VA Form 10-2850D will assist VA to be compliant with key screening requirements for trainees with less of a burden on trainees and VA officials responsible for the screening process. Only trainees that meet established qualifications and security requirements based on the information in form 10-2850D will be appointed to VA.

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Annual Cost to Federal Government: $1,968,650

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:  Yes

Description/Changes for Common Form Usage:  Previously, OMB approved VA Form 10-2850d as part of a collection of forms under OMB number: 2900-0205 APPLICATIONS AND APPRAISALS FOR EMPLOYMENT FOR TITLE 38 POSITIONS AND TRAINEES -- VA Forms of the 10-2850 SERIES and the FL 10-431 SERIES. The VA Form 2850D presented in this ICR is the same as that previously approved by OMB as part of 2900-0205.

Approved RCFs using this ICR

table that charts list of RCF

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

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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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