Information Collection

10-10143e Secondary Authorization Request (SAR) for VA Community Care

IC 221260 under ICR 202008-2900-001 · OMB 2900-0823.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10143e 10-10143e Secondary Authorization Request (SAR) for VA Community Care	Form
10-10143e SAR for VA Community Care VA Form 10-10143e_Secondary Auth Request_ Community Care.pdf	Form

IC Title:

Agency IC Tracking Number:

2900-0823

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-10143e	SAR for VA Community Care	VA Form 10-10143e_Secondary Auth Request_ Community Care.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 366,823

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,834,115	1,834,115
Annual IC Time Burden (Hours)	611,372	611,372
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.