OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

WRITTEN CONSENT TO RELEASE MEDICAL RECORDS PROTECTED_BY 38 U.S.C. 7332 -- 38 CFR 1.475(A)

ICR 199307-2900-012 · OMB 2900-0544 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
148397 WRITTEN CONSENT TO RELEASE MEDICAL RECORDS PROTECTED_BY 38 U.S.C. 7332 -- 38 CFR 1.475(A) Migrated
ICR Details
2900-0544 199307-2900-012
Historical Active
VA
WRITTEN CONSENT TO RELEASE MEDICAL RECORDS PROTECTED_BY 38 U.S.C. 7332 -- 38 CFR 1.475(A)
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 10/24/1993
Retrieve Notice of Action (NOA) 07/22/1993
  Inventory as of this Action Requested Previously Approved
10/31/1996 10/31/1996
1 0 0
1,720 0 0
0 0 0
THIS INFORMATION IS USED TO OBTAIN WRITTEN CONSENT OF PATIENTS TO RELEASE INFORMATION PERTAINING TO TREATMENT FOR DRUG OR ALCOHOL ABUSE, SICKLE CELL ANEMIA, AND INFECTION WITH HIV.
None
None
No
1
IC Title Form No. Form Name
WRITTEN CONSENT TO RELEASE MEDICAL RECORDS PROTECTED_BY 38 U.S.C. 7332 -- 38 CFR 1.475(A)
  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 1 0 0 1 0 0
Annual Time Burden (Hours) 1,720 0 0 1,720 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
07/22/1993