05-204. Proposed Information Collection Activity: Proposed Collection; Comment Request

AGENCY:

Veterans Health Administration, Department of Veterans Affairs.

ACTION:

Notice.

SUMMARY:

The Veterans Health Administration (VHA) is announcing an opportunity for public comment on the proposed collection of certain information by the agency. Under the Paperwork Reduction Act (PRA) of 1995, Federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information, including each proposed extension of a currently approved collection, and allow 60 days for public comment in response to the notice. This notice solicits comments on information needed to determine eligibility for extended care benefits.

DATES:

Written comments and recommendations on the proposed collection of information should be received on or before March 7, 2005.

ADDRESSES:

Submit written comments on the collection of information to Ann Bickoff, Veterans Health Administration (193E1), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420 or e-mail [e-mail]. Please refer to “OMB Control No. 2900-0629” in any correspondence.

FOR FURTHER INFORMATION CONTACT:

Ann Bickoff at [phone].

SUPPLEMENTARY INFORMATION:

Under the PRA of 1995 (Public Law 104-13; 44 U.S.C. 3501-3521), Federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. This request for comment is being made pursuant to Section 3506(c)(2)(A) of the PRA.

With respect to the following collection of information, VHA invites comments on: (1) Whether the proposed collection of information is necessary for the proper performance of VHA's functions, including whether the information will have practical utility; (2) the accuracy of VHA's estimate of the burden of the proposed collection of information; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) ways to minimize the burden of the collection of information on respondents, including through the use of automated collection techniques or the use of other forms of information technology.

Title: Application for Extended Care Services, VA Form 10-10EC.

OMB Control Number: 2900-0629.

Type of Review: Extension of a currently approved collection.

Abstract: VA Form 10-10EC is used to gather current income and financial information from nonservice-connected veterans and their spouse applying for extended care services. VA uses the data collected to establish veteran's eligibility for extended care services, financial liability, if any, to pay if accepted for placement or treatment in extended care services, and the applicable co-payment.

Affected Public: Individuals or Households.

Estimated Total Annual Burden: 9,000 hours.

Estimated Average Burden Per Respondent: 90 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents: 6,000.

Dated: December 22, 2004.

By direction of the Secretary:

Jacqueline Parks,

IT Specialist, Records Management Service.