Information Collection

Statement of Assurance of Compliance with Equal Opportunity Laws

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Assurance of Compliance with Equal Opportunity Laws	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:

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 %

	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

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.