Information Collection

10-10143f - Community Care Document Cover Sheet

IC 241051 under ICR 201905-2900-007 · OMB 2900-0823.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0823 can be found here:

Documents and Forms

Document Name Document Type
Form 10-10143f 10-10143f - Community Care Document Cover Sheet Form and Instruction
10-10143f Community Care Document Cover Sheet VA Form 10-10143f_Community Care Document Cover Sheet.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	10-10143f - Community Care Document Cover Sheet	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10143f	Community Care Document Cover Sheet	VA Form 10-10143f_Community Care Document Cover Sheet.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500,000	500,000
Annual IC Time Burden (Hours)	41,667	41,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.