VA Advance Directive - Durable Power of Attorney for Health Care and Living Will

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-0137 VA Advance Directive - Durable Power of Attorney for Health Care and Living Will - Spanish_English	Form and Instruction	Removed	Available
Form 10-0137 VA Advance Directive - Durable Power of Attorney for Health Care and Living Will	Form and Instruction	Removed	Repair queued
Memorandum_Request for Emergency PRA Clearance_VA Advance Directive_2900-0556 - (5-7-20) MS signed.docm	Supporting Statement A	Uploaded 2020-05-07	Available
Memorandum_Request for Emergency PRA Clearance_VA Advance Directive_2900-0556 - (5-7-20) MS signed.docm	Supplementary Document	Uploaded 2020-05-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28738	Durable Power of Attorney for Health Care and Living Will, VA Advance Directive	Form and Instruction	Removed	VA Advance Directive - Durable Power of Attorney for Health Care and Living Will - Spanish_English
28738	Durable Power of Attorney for Health Care and Living Will, VA Advance Directive	Form and Instruction	Removed	VA Advance Directive - Durable Power of Attorney for Health Care and Living Will
241723	Close Personal Friend Statement of Relationship to Veteran		New

ICR Details

OMB Control No: 2900-0556	ICR Reference No: 202005-2900-003
Status: Historical Active	Previous ICR Reference No: 201704-2900-012
Agency/Subagency: VA	Agency Tracking No: 2900-0556
Title: VA Advance Directive - Durable Power of Attorney for Health Care and Living Will
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 05/08/2020
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/02/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/07/2020
Terms of Clearance: Emergency approval is granted. VA shall proceed with the normal clearance process in order to avoid a lapse in OMB approval. VA shall accept the close personal friend statement approved under this control number in any reasonable manner. If VA wishes to require a specific format or method of submission, VA shall submit for OMB review.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2020	6 Months From Approved	12/31/2020
Responses	300	0	343,622
Time Burden (Hours)	50	0	171,811
Cost Burden (Dollars)	0	0	0

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Abstract: Section 7331 of title 38, United States Code (U.S.C.), requires, in relevant part, that the Secretary of Veterans Affairs, upon the recommendation of the Under Secretary for Health, prescribe regulations to ensure, to the maximum extent practicable, that all VA patient care be carried out only with the full and informed consent of the patient, or in appropriate cases, a representative thereof. Based on VA’s interpretation of this statute and our mandate in 38 U.S.C. 7301(b) to provide a complete medical and hospital service, we recognize that patients with decision-making capacity have the right to state their treatment preferences in a VA or other valid advance directive. The VA advance directive form (both English and Spanish language versions) is VA Form 10-0137. These forms have a current OMB Paperwork Reduction Act (PRA) clearance under OMB Control Number 2900-0556. When a Veteran is incapacitated and does not have an advance directive, the VA regulations allow a statement to be submitted from a “Close Personal Friend” who will be responsible for making health care decisions on behalf of the Veteran. This request for an emergency PRA clearance applies to the addition of the collection of a “Close Personal Friend Statement” to 2900-0556.

Emergency Justfication: This request for an emergency PRA clearance applies to the addition of the collection of a “Close Personal Friend Statement” to 2900-0556. It is estimated that 300 statements will be collected annually, with a burden of 10 minutes per statement. This information collection is noticed in the interim final rule associated with RIN 2900-AQ97. Emergency clearance is requested because AQ97 changed from a proposed rule to an interim final rule that will soon be cleared for publication in the Federal Register. The use of regular OMB clearance procedures will not allow for coordination of the PRA clearance with publication of the rule.

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Authorizing Statute(s): US Code: 38 USC 7331 Name of Law: Informed consent
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AQ97	Final or interim final rulemaking	85 FR 31690	05/27/2020

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Federal Register Notices & Comments

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
Close Personal Friend Statement of Relationship to Veteran
Durable Power of Attorney for Health Care and Living Will, VA Advance Directive	10-0137, 10-0137	VA Advance Directive - Durable Power of Attorney for Health Care and Living Will ,   VA Advance Directive - Durable Power of Attorney for Health Care and Living Will - Spanish_English

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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	300	343,622	0	-343,322	0	0
Annual Time Burden (Hours)	50	171,811	0	-171,761	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: VA Forms 10-0137, English and Spanish language versions, are currently approved for a PRA clearance until 12/31/2020. Therefore, the burden for these forms has been removed from this emergency clearance request. VA is requesting this emergency PRA clearance for the addition of the collection of a Close Personal Friend Statement from approximately 300 persons per year, pursuant to interim final rule with RIN 2900-AQ97. Only the burden for this additional information collection is included in this request for emergency PRA clearance.

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Annual Cost to Federal Government: $0

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: 05/07/2020

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