03-21234. Agency Information Collection Activities Under OMB Review

AGENCY:

Veterans Health Administration, Department of Veterans Affairs.

ACTION:

Notice.

SUMMARY:

In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C., 3501 et seq.), this notice announces that the Veterans Health Administration (VHA), Department of Veterans Affairs, has submitted the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden; it includes the actual data collection instrument.

DATE:

Comments must be submitted on or before September 19, 2003.

FOR FURTHER INFORMATION OR A COPY OF THE SUBMISSION CONTACT:

Denise McLamb, Information Management Service (045A4), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, [phone], Fax [phone] or e-mail to: [e-mail]. Please refer to “OMB Control No. 2900-0160.”

Send comments and recommendations concerning any aspect of the information collection to VA's OMB Desk Officer, OMB Human Resources and Housing Branch, New Executive Office Building, Room 10235, Washington, DC 20503, [phone]. Please refer to “OMB Control No. 2900-0160” in any correspondence.

SUPPLEMENTARY INFORMATION:

Titles:

a. State Home Inspection—Staffing Profile, VA Form 10-3567.

b. State Home Report and Statement of Federal Aid Claimed, VA Form 10-5588.

c. State Home Program Application for Veterans Care—Medical Certification, VA Form 10-10SH.

d. Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals, VA Form 10-0143.

e. Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, VA Form 10-1043A.

f. Certification Regarding Lobbying, VA Form 10-0144.

g. Statement of Assurance of Compliance with Equal Opportunity Law, VA Form 10-0144A.

h. Per Diem for Adult Day Health Care of Veterans in State Homes, 38 CFR part 52, and Per Diem for Nursing Home Care of Veterans in State Homes, 38 CFR parts 17, 51, and 48.

OMB Control Number: 2900-0160.

Type of Review: Extension of a currently approved collection.

Abstract: VA pays per diem to State homes providing adult day health care to eligible veterans. To ensure high quality care is furnished to the veterans, VA requires those facilities providing adult day health care to furnish an application for recognition based on certification; appeal information, application and justification for payment; records and reports which facility management must maintain regarding activities of residents or participants; information relating to whether the facility meets standards concerning residents' rights and responsibilities prior to admission or enrollment, during admission or enrollment, and upon discharge; the records and reports which facilities management and health care professionals must maintain regarding residents or participants and employees; documents pertaining to the management of the facilities; food menu planning; pharmaceutical records; and life safety documentation. This information is necessary to ensure that VA per diem payments are limited to facilities providing high quality care to eligible veterans.

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The Federal Register notice with a 60-day comment period soliciting comments on this collection of information was published on May 6, 2003, at pages 24048-24050.

Affected Public: State, Local or Tribal Government, Individuals or Households, and Not-For-Profit Institutions.

Estimated Total Annual Burden: 15,886 hours.

a. State Home Inspection—Staffing Profile, VA Form 10-3567—86 hours.

b. State Home Report and Statement of Federal Aid Claimed, VA Form 10-5588—1,026 hours.

c. State Home Program Application for Veterans Care—Medical Certification, VA Form 10-10SH—10,565 hours.

d. Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals, VA Form 10-0143—21 hours.

e. Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, VA Form 10-0143A—21 hours.

f. Certification Regarding Lobbying, VA Form 10-0144—21 hours.

g. Statement of Assurance of Compliance with Equal Opportunity Law, VA Form 10-0144A—21 hours.

h. Per Diem for Adult Day Health Care of Veterans in State Homes, 38 CFR Part 52, and Per Diem for Nursing Home Care of Veterans in State Homes, 38 CFR Parts 17, 51, and 48—4,125 hours.

Estimated Average Burden Per Respondent:

a. State Home Inspection—Staffing Profile, VA Form 10-3567—30 minutes.

b. State Home Report and Statement of Federal Aid Claimed, VA Form 10-5588—30 minutes.

c. State Home Program Application for Veterans Care—Medical Certification, VA Form 10-10SH—30 minutes.

d. Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals, VA Form 10-0143—7 minutes.

e. Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, VA Form 10-0143A—7 minutes.

f. Certification Regarding Lobbying, VA Form 10-0144—7 minutes.

g. Statement of Assurance of Compliance with Equal Opportunity Law, VA Form 10-0144A—7 minutes.

h. Per Diem for Adult Day Health Care of Veterans in State Homes, 38 CFR Part 52, and Per Diem for Nursing Home Care of Veterans in State Homes, 38 CFR Parts 17, 51, and 48—7 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents: 43,157.

a. State Home Inspection—Staffing Profile, VA Form 10-3567—171.

b. State Home Report and Statement of Federal Aid Claimed, VA Form 10-5588—171.

c. State Home Program Application for Veterans Care—Medical Certification, VA Form 10-10SH—21,129.

d. Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals, VA Form 10-0143—171.

e. Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, VA Form 10-0143A—171.

f. Certification Regarding Lobbying, VA Form 10-0144—171.

g. Statement of Assurance of Compliance with Equal Opportunity Law, VA Form 10-0144A—171.

h. Per Diem for Adult Day Health Care of Veterans in State Homes, 38 CFR Part 52, and Per Diem for Nursing Home Care of Veterans in State Homes, 38 CFR Parts 17, 51, and 48—21,002.

Dated: July 28, 2003.

By direction of the Secretary.

Jacqueline Parks,

IT Specialist, Records Management Service.