Information Collection

Statement of Assurance of Compliance with Equal Opportunity Laws

IC 242719 under ICR 202306-2900-012 · OMB 2900-0883.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-0144A Statement of Assurance of Compliance with Equal Opportunity Laws	Form
10-0144A Statement of Assurance of Compliance with Equal Opportun VA Form 10-0144A.pdf www.va.gov/vaforms/	Form
10-0144A Statement of Assurance of Compliance with Equal Opportun VA Form 10-0144A.pdf www.va.gov/vaforms/	Form

IC Title:

Agency IC Tracking Number:

2900-NEW

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 51

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	10-0144A	Statement of Assurance of Compliance with Equal Opportunity Laws	VA Form 10-0144A.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 165

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	165	9	156
Annual IC Time Burden (Hours)	14	1	13
Annual IC Cost Burden (Dollars)	0	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.