VA Advance Directive - Durable Power of Attorney for Health Care and Living Will (VA Form 10-0137)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-0137 VA Advance Directive - Durable Power of Atttorney for Health Care and Living WIll (English-Spanish)	Form and Instruction	Modified	Available
Form 10-0137 VA Advance Directive - Durable Power of Attorney for Health Care and Living Will	Form and Instruction	Modified	Available
Form 10-0137 VA Form 10-0137	Form and Instruction	Unchanged	Repair queued
30-day FRN_2900-0556_VA Advance Directive_POA for Health Care & Living Will_published 02262024.pdf	Supplementary Document	Uploaded 2024-02-26	Repair queued
60-day FRN_2900-0556_VA Advance Directive_POA for Health Care & Living Will_published 12182023.pdf	Supplementary Document	Uploaded 2024-02-06	Repair queued
Supp Stmnt A_2900-0556_VA Adv Directive - POA for Health Care & Living Will_updated Feb 2024.docx	Supporting Statement A	Uploaded 2024-02-26	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
242471	VA Form 10-0137	Form and Instruction	Modified	VA Advance Directive - Durable Power of Atttorney for Health Care and Living WIll (English-Spanish)
242471	VA Form 10-0137	Form and Instruction	Modified	VA Advance Directive - Durable Power of Attorney for Health Care and Living Will
242471	VA Form 10-0137	Form and Instruction	Unchanged
241723	Close Personal Friend Statement of Relationship to Veteran		Unchanged

ICR Details

OMB Control No: 2900-0556	ICR Reference No: 202312-2900-003
Status: Active	Previous ICR Reference No: 202010-2900-001
Agency/Subagency: VA	Agency Tracking No: 2900-0556
Title: VA Advance Directive - Durable Power of Attorney for Health Care and Living Will (VA Form 10-0137)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/24/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/26/2024
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time the agency will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2027	36 Months From Approved	04/30/2024
Responses	343,922	0	343,922
Time Burden (Hours)	171,861	0	171,861
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. In addition, 2900-0556 includes the collection of a “Close Personal Friend Statement” for incapacitated Veterans who have not completed an Advance Directive and are in need of health care. 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. It is estimated that 300 such statements will be collected annually.

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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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 87500	12/18/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 14155	02/26/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Close Personal Friend Statement of Relationship to Veteran
VA Form 10-0137	10-0137, 10-0137	VA Advance Directive - Durable Power of Attorney for Health Care and Living Will ,   VA Advance Directive - Durable Power of Atttorney for Health Care and Living WIll (English-Spanish)

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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	343,922	343,922	0	0	0	0
Annual Time Burden (Hours)	171,861	171,861	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $6,379,342

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: 02/26/2024

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