OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

REQUEST FOR CERTIFICATION OF MEDICAL TREATMENT BY ATTENDING PHYSICIAN

ICR 198011-2900-026 · OMB 2900-0035 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
174108 REQUEST FOR CERTIFICATION OF MEDICAL TREATMENT BY ATTENDING PHYSICIAN Form Migrated
ICR Details
2900-0035 198011-2900-026
Historical Active 197704-2900-004
VA
REQUEST FOR CERTIFICATION OF MEDICAL TREATMENT BY ATTENDING PHYSICIAN
No material or nonsubstantive change to a currently approved collection   No
Emergency 11/06/1980
Approved with change 11/06/1980
Retrieve Notice of Action (NOA) 11/06/1980
  Inventory as of this Action Requested Previously Approved
03/31/1982 03/31/1982 03/31/1982
32,000 0 34,000
5,333 0 5,667
0 0 0
THIS LETTER IS USED TO SOLICIT INFORMATION FROM A PRIVATE PHYSICIAN, WITH THE CONSENT OF THE VETERAN, WHO HAS TREATED THE VETERAN. THE CLINICAL FINDINGS, SYMTOMATOLOGY, DIAGNOSES, ETC. FURNISHED WILL BE USED TO SUPPORT THE VETERAN'S CLAIM FOR DISABILITY BENEFITS. THIS TYPE OF EVIDENCE IS SECURED TO INSURE THAT ALL PERTINENT INFORMATION IS CONSIDERED IN THE ADJUDICATION OF THE VETERAN'S CLAIM. AUTHORITY IS UNDER 38 C.F.R. 3.326
None
None
No
1
IC Title Form No. Form Name
REQUEST FOR CERTIFICATION OF MEDICAL TREATMENT BY ATTENDING PHYSICIAN FL21-104
  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 32,000 34,000 0 -2,000 0 0
Annual Time Burden (Hours) 5,333 5,667 0 -334 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
11/06/1980