Veteran/Beneficiary Claim for Reimbursement of Travel Expenses (VA Form 10-3542 and BTSSS)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-3542 VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES	Form and Instruction	Modified	Available
Form VA Form 10-3542 VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES	Form and Instruction	Modified	Repair queued
2900-0798_Emergency OMB PRA Clearance Request Memorandum_(VA Form 10-3542 and BTSSS)_02082024.pdf	Supplementary Document	Uploaded 2024-02-08	Repair queued
Supporting Statement A_2900-0798_Veteran-Beneficiary Claim for Reimbursement of Travel Expenses_10-3542 and BTSSS_updated 02082024.docx	Supporting Statement A	Uploaded 2024-02-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206581	VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES	Form and Instruction	Modified	VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES
206581	VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES	Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0798	ICR Reference No: 202402-2900-007
Status: Historical Inactive	Previous ICR Reference No: 201604-2900-019
Agency/Subagency: VA	Agency Tracking No: 2900-0798
Title: Veteran/Beneficiary Claim for Reimbursement of Travel Expenses (VA Form 10-3542 and BTSSS)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 02/09/2024
OIRA Conclusion Action: Withdrawn	Conclusion Date: 09/17/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/08/2024
Terms of Clearance: Withdrawn at the request of VA.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		6 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Through the Beneficiary Travel (BT) program, Veterans Health Administration (VHA) provides mileage reimbursement to qualified Veterans or other claimants (referred to as “claimant” hereafter) who incur expense in traveling to healthcare. Determination criteria for claimant qualification and trip reimbursement are stated in 38 U.S.C. Section 111 and require certain information to be gathered. Claimants may apply verbally, in writing (using VA Form 10-3542) or electronically (using the Beneficiary Travel Self Service System (BTSSS)). The same information is gathered in all instances. The form is used only when the claimant chooses not to apply verbally or electronically. This collection of information is necessary to enable the VHA to provide this benefit and appropriately ensure that funds are being paid to the correct claimant.

Emergency Justfication: The PRA clearance for this information collection expired on 7/31/2020. VA respectfully requests an emergency reinstatement of the OMB clearance approval for 2900-0798 so that the Veteran/beneficiary medical travel expense reimbursement program may continue while we publish the required FRNs and follow the process for a 3-year PRA clearance renewal.

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Authorizing Statute(s): US Code: 38 USC Section 111 Name of Law: Payments or allowances for beneficiary travel
  

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

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
VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES	VA Form 10-3542	VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES

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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: No

Burden Reduction Due to:

Short Statement: Burden increase is due to use of program historical data and an increase in the estimated number of minutes for a respondent to complete a claim for reimbursement.

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Annual Cost to Federal Government: $29,205,840

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: 02/08/2024

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