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Federal forms, ICRs, and supporting documents

Information Collection Request

REQUEST FOR AND CONSENT TO RELEASE OF DRUG ABUSE, ALCOHOLISM, OR ALCOHOL ABUSE OR SICKLE CELL ANEMIA INFORMATION FROM MEDICAL RECORDS

ICR 198409-2900-012 · OMB 2900-0260 · Historical Active

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147813 REQUEST FOR AND CONSENT TO RELEASE OF DRUG ABUSE, ALCOHOLISM, OR ALCOHOL ABUSE OR SICKLE CELL ANEMIA INFORMATION FROM MEDICAL RECORDS Form Migrated
ICR Details
2900-0260 198409-2900-012
Historical Active 198110-2900-008
VA
REQUEST FOR AND CONSENT TO RELEASE OF DRUG ABUSE, ALCOHOLISM, OR ALCOHOL ABUSE OR SICKLE CELL ANEMIA INFORMATION FROM MEDICAL RECORDS
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 11/16/1984
Retrieve Notice of Action (NOA) 09/20/1984
  Inventory as of this Action Requested Previously Approved
09/30/1987 09/30/1987
421,908 0 0
21,095 0 0
0 0 0
WRITTEN CONSENT IS REQUIRED BY 38 USC 4132 AS IMPLEMENTED BY 42 CFR 2.31(A)(1)-(8) AND 2.32 IN ORDER TO RELEASE DRUG, ALCOHOL AND SICKE CELL ANEMIA INFORMATION. INDIVIDUAL VETERANS WILL COMPLETE FORM IN ORDER TO RELEASE INFORMATION.
None
None
No
  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 421,908 0 0 0 421,908 0
Annual Time Burden (Hours) 21,095 0 0 0 21,095 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$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.
09/20/1984