[Federal Register Volume 60, Number 160 (Friday, August 18, 1995)]
[Notices]
[Pages 43184-43186]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-20568]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF VETERANS AFFAIRS
Information Collections Under OMB Review
AGENCY: Veterans Health Administration, Department of Veterans Affairs.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: Veterans Health Administration (VHA), Department of Veterans
Affairs, has submitted to the Office of Management and Budget (OMB) the
following proposals for the collection of information under the
provisions of the Paperwork Reduction Act (44 U.S.C. Chapter 35).
[[Page 43185]]
OMB Number: 2900-0208.
Title and Form Number: Architect-Engineer Fee Proposal, VA Form 08-
6298.
Type of Information Collection: Extension of a currently approved
collection.
Needs and Uses: The form is used by architect-engineering firms to
submit a fee proposal on the scope and complexity of an individual
project. The information is used in the negotiation of a fair and
reasonable contract for services.
Affected Public: Business or other for-profit.
Estimated Annual Burden: 800 hours.
Estimated Average Burden Per Respondent: 4 hours
Frequency of Response: One-time.
Estimated Number of Respondents: 200 respondents.
OMB Number: 2900-0080.
Titles and Form Number: Authorization and Invoice for Medical and
Hospital Services; VA Form 10-7078(R); Claim for Payment of Cost of
Unauthorized Medical Services; VA Form 10-583(R); and Authority and
Invoice for Travel by Ambulance or Other Hired Vehicle, VA Form 10-
2511(R).
Type of Information Collection: Reinstatement, without change, of a
previously approved collection for which approval has expired.
Needs and Uses:
a. VA Form 10-7078(R) is used to authorize expenditures from the
medical care account and process payment of medical and hospital
services provided by other than Federal health providers to VA
beneficiaries.
b. VA Form 10-583(R) is used to collect information for determining
the legal and medical eligibility of applicants for payment or
reimbursement of the costs of unauthorized medical service obtained by
a veteran.
c. VA Form 10-2511(R) is used to authorize expenditures from the
beneficiary travel account and process payment for ambulance or other
hired vehicular forms of transportation for eligible veterans to and
from VA health care facilities for examination, treatment or care.
Affected Public: Business or other for-profit--Individual or
households--Not-for-profit institutions--Federal Government--State,
Local or Tribal Government.
Estimated Annual Burden: 29,671 total hours.
a. VA Form 10-7078(R)--8,400.
b. VA Form 10-583(R)--4,083.
c. VA Form 10-2511(R)--17,188.
Estimated Average Burden Per Respondent:
a. VA Form 10-7078(R)--2 minutes.
b. VA Form 10-583(R)--15 minutes.
c. VA Form 10-2511(R)--2 minutes.
Frequency of Response: On occasion.
Estimated Number of Respondents: 443,250 total respondents.
a. VA Form 10-7078(R)--252,000 respondents.
b. VA Form 10-583(R)--68,760 respondents.
c. VA Form 10-2511(R)--122,500 respondents.
OMB Number: 2900-0160.
Title and Form Number: Application for Furnishing Nursing Home Care
to Beneficiaries of Veterans Affairs, VA Form 10-1170; State Home
Report and State Month of Federal Aid Claimed, VA Form 10-5588; and
Residential Care Home Program--Sponsor Application, VA Form 10-2407.
Type of Information Collection: Reinstatement, without change, of a
previously approved collection for which approval has expired.
Needs and Uses:
a. VA Form 10-1170 is used by non Federal nursing homes to qualify
to provide care to veterans patients.
b. VA Form 10-5588 is used by State Homes to request reimbursement
for care provided to veteran patients.
c. VA Form 10-2407 is used by applicants to apply to VHA to become
a sponsor in the Residential Care Home Program.
Affected Public: Business or other for-profit--Individuals or
households--State, Local or Tribal Government.
Estimated Annual Burden: 315 total hours.
a. VA Form 10-1170--133 hours.
b. VA Form 10-5588--110 hours.
c. VA Form 10-2407--72 hours.
Estimated Average Burden Per Respondent:
a. VA Form 10-1170--20 minutes.
b. VA Form 10-5588--30 minutes.
c. VA Form 10-2407--5 minutes.
Frequency of Response:
a. VA Form 10-1170--Annually.
b. VA Form 10-5588--Quarterly.
c. VA Form 10-2407--Annually.
Estimated Number of Respondents: 1,315 total respondents.
a. VA Form 10-1170--400 respondents.
b. VA Form 10-5588--220 respondents.
c. VA Form 10-2407--860 respondents.
OMB Number: 2900-0219.
Title and Form Number: Application for CHAMPVA Benefits, VA Form
10-10D; CHAMPVA Claim Form, VA Form 10-7959A; Other Health Insurance
(OHI) Certification, VA Form 10-7959C; and Potential Liability Claim,
VA Form 10-7959D
Type of Information Collection: Reinstatement, with change, of a
previously approved collection for which approval has expired.
Needs and Uses:
a. VA Form 10-10D is used to determine eligibility of persons
applying for medical care under CHAMPVA (Civilian Health and Medical
Program of Veterans Affairs).
b. VA Form 10-7959A is used adjudicate claims for CHAMPVA benefits.
c. VA Form 10-7959C is used to obtain annual other health insurance
information and to correctly coordinate benefits among all liable
parties.
d. VA Form 7959D is used in the recovery of costs associated with
medical services related to an injury/illness caused by a third party.
Affected Public: Individuals or households--Business or other for-
profit--Not-for-profit institutions.
Estimated Annual Burden: 30,033 total hours.
a. VA Form 10-10D--800 hours.
b. VA Form 10-7959A--20,000 hours.
c. VA Form 10-7959C--6,200 hours.
d. VA Form 10-7959D--3,033 hours.
Estimated Average Burden Per Respondent:
a. VA Form 10-10D--5 minutes.
b. VA Form 10-7959A--4 minutes.
c. VA Form 10-7959C--6 minutes.
d. VA Form 10-7959D--7 minutes.
Frequency of Response:
a. VA Form 10-10D--Annually.
b. VA Form 10-7959A--Annually.
c. VA Form 10-7959C--Annually.
d. VA Form 10-7959D--On occasion.
Estimated Number of Respondents: 397,600 total respondents.
a. VA Form 10-10D--9,600 respondents.
b. VA Form 10-7959A--300,000 respondents.
c. VA Form 10-7959C--62,000 respondents.
d. VA Form 10-7959D--26,000 respondents.
Estimated Number of Respondents: 10,000 respondents.
OMB Number: 2900-0427
Title and Form Number: Former POW Medical History, VA Form 10-0048.
Type of Information Collection: Reinstatement, without change, of a
previously approved collection for which approval has expired.
Needs and Uses: The information is obtained from former POWs to
assess the medical care needs of these veterans. The information will
be used to determine the present and future
[[Page 43186]]
needs of POWs in the areas of disability compensation, health care and
rehabilitation.
Affected Public: Individuals or households.
Estimated Annual Burden: 750 hours.
Estimated Average Burden Per Respondent: 1 hour
Frequency of Response: Non-recurring.
Estimated Number of Respondents: 750 respondents.
ADDRESSES: Copies of these submissions may be obtained from Ann
Bickoff, Veterans Health Administration (161B4), Department of Veterans
Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 565-7407.
Comments and recommendations concerning the submissions should be
directed to VA's OMB Desk Officer, Allison Eydt, OMB Human Resources
and Housing Branch, New Executive Office Building, Room 10235,
Washington, DC 20503 (202) 395-4650. DO NOT send requests for benefits
to this address.
DATES: Comments on the information collections should be directed to
the OMB Desk Officer on or before September 18, 1995.
FOR FURTHER INFORMATION CONTACT: Ron Taylor, VA Clearance Officer
(045A4), (202) 565-4412.
Dated: August 10, 1995.
By direction of the Secretary:
Donald L. Neilson,
Director, Information Management Service.
[FR Doc. 95-20568 Filed 8-17-95; 8:45 am]
BILLING CODE 8320-01-P
