OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENT TO RECOVERY FOR INJURY OR DEATH

ICR 199308-2900-009 · OMB 2900-0545 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
148398 REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENT TO RECOVERY FOR INJURY OR DEATH Form Migrated
ICR Details
2900-0545 199308-2900-009
Historical Active
VA
REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENT TO RECOVERY FOR INJURY OR DEATH
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 10/25/1993
Retrieve Notice of Action (NOA) 08/16/1993
  Inventory as of this Action Requested Previously Approved
10/31/1995 10/31/1995
10,000 0 0
7,500 0 0
0 0 0
VA FORM 21-8416B WILL BY USED TO REPORT EXPENSES INCURRED BY A BENEFICIARY INCIDENT TO RECOVERY OF BENEFITS RESULTING FROM AN AWARD O COMPENSATION FOR INJURY, ILLNESS, OR DEATH.
None
None
No
1
IC Title Form No. Form Name
REPORT OF MEDICAL, LEGAL, AND OTHER EXPENSES INCIDENT TO RECOVERY FOR INJURY OR DEATH VA 21-8416B
  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 10,000 0 0 10,000 0 0
Annual Time Burden (Hours) 7,500 0 0 7,500 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.
08/16/1993