OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

RIN 2900-AO79 Reimbursement of Certain Medical Expenses for Camp Lejeune Family Members

ICR 201403-2900-015 · OMB 2900-0822 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 10-10068c Camp Lejeune Family Member Program Information Update Form Form and Instruction New Available
Form 10-10068b Camp Lejeune Family Member Program Treating Physician Report Form and Instruction New Available
Form 10-10068a Camp Lejeune Family Member Program Claim Form Form and Instruction New Repair queued
Form 10-10068 Camp Lejeune Family Member Program Application Form and Instruction New Available
AO79(IF)-Impact Analysis (6-4-13 f)-VHA-CampLejeune FM.DOCX Supplementary Document Uploaded 2014-03-26 Available
Justification A_Camp Lejeune (clean).doc Supporting Statement A Uploaded 2014-09-17 Repair queued
Emergency Clearance Request AO79 Camp Lejeune.doc Justification for No Material/Nonsubstantive Change Uploaded 2014-03-26 Available
IC Document Collections
IC IDCollectionTypeStatusForm
210897 Camp Lejeune Family Member Program Information Update Form Form and Instruction New
210896 Camp Lejeune Family Member Program Treating Physician Report Form and Instruction New
210895 Camp Lejeune Family Member Program Claim Form Form and Instruction New
210894 Camp Lejeune Family Member Program Application Form and Instruction New
ICR Details
2900-0822 201403-2900-015
Historical Active
VA
RIN 2900-AO79 Reimbursement of Certain Medical Expenses for Camp Lejeune Family Members
New collection (Request for a new OMB Control Number)   No
Emergency 04/28/2014
Approved with change 09/30/2014
Retrieve Notice of Action (NOA) 03/26/2014
  Inventory as of this Action Requested Previously Approved
03/31/2015 6 Months From Approved
21,720 0 0
5,838 0 0
0 0 0
The Department of Veterans Affairs (VA) promulgates regulations to implement statutory authority to provide reimbursement for hospital care and medical services provided to certain veterans' family members who resided at Camp Lejeune, North Carolina, for at least 30 days during the period beginning on January 1, 1957, and ending on December 31, 1987. Under this rule, VA will reimburse family members for medical expenses incurred as a result of certain illnesses and conditions that may be attributed to exposure to contaminated drinking water at Camp Lejeune during this time period. Reimbursement will be made within the limitations set forth in statute. In order to furnish such care, VA must collect certain information from the family members to ensure that they meet the requirements of the law.
Under 38 U.S.C. 1787, VA is required to furnish hospital care and medical services to the family members of certain veterans who were stationed at Camp Lejeune between 1957 and 1987. In order to furnish such care, VA must collect certain information from the family members to ensure that they meet the requirements of the law. VA cannot furnish the statutorily-mandated hospital care and medical services until the collection of information is approved. The specific hospital care and medical services that VA must provide are for a number of illnesses and conditions connected to exposure to contaminated drinking water while at Camp Lejeune. Many of these conditions are life-threatening and require immediate medical attention. Therefore, VA certifies that the collection of information meets each of the listed criteria.
US Code: 38 USC 1787 Name of Law: Health care of family members of veterans stationed at Camp Lejeune, North Carolina
  
US Code: 38 USC 1787 Name of Law: Health care of family members of veterans stationed at Camp Lejeune, North Carolina
2900-AO79 Final or interim final rulemaking 12 FR 3456 03/28/2014
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 21,720 0 21,720 0 0 0
Annual Time Burden (Hours) 5,838 0 5,838 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
Due to a new Statue this will be an increase in burden hours.
$91,335
No
No
No
No
No
Uncollected
Crystal Rennie 202 632-7492 [email protected]
  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.
03/26/2014