OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Reimbursement of Certain Medical Expenses for Camp Lejeune Family Members

ICR 201412-2900-005 · OMB 2900-0822 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 10-10068c Camp Lejeune Family Member Program Information Update Form Form and Instruction Modified Repair queued
Form 10-10068b Camp Lejeune Family Member Program Treating Physician Report Form and Instruction Modified Repair queued
Form 10-10068a Camp Lejeune Family Member Program Claim Form Form and Instruction Modified Available
Form 10-10068 Camp Lejeune Family Member Program Application Form and Instruction Modified Available
2900-0822 30 day FRN-1.docx Supplementary Document Uploaded 2015-05-06 Available
2900-0822 Nonsub change_dates_GO_20141231.docx Justification for No Material/Nonsubstantive Change Uploaded 2014-12-31 Available
AO79(IF)-Impact Analysis (6-4-13 f)-VHA-CampLejeune FM.DOCX Supplementary Document Uploaded 2014-03-26 Available
201412-2900-005_Justification A_Camp Lejeune _OMB Comments 2015 (BW edits)_clean 6-26-15.doc Supporting Statement A Uploaded 2015-06-26 Repair queued
Emergency Clearance Request AO79 Camp Lejeune.doc Justification for No Material/Nonsubstantive Change Uploaded 2014-03-26 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
210897 Camp Lejeune Family Member Program Information Update Form Form and Instruction Modified
210896 Camp Lejeune Family Member Program Treating Physician Report Form and Instruction Modified
210895 Camp Lejeune Family Member Program Claim Form Form and Instruction Modified
210894 Camp Lejeune Family Member Program Application Form and Instruction Modified
ICR Details
2900-0822 201412-2900-005
Historical Active 201403-2900-015
VA VHA
Reimbursement of Certain Medical Expenses for Camp Lejeune Family Members
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 07/09/2015
Retrieve Notice of Action (NOA) 05/18/2015
  Inventory as of this Action Requested Previously Approved
07/31/2018 36 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.
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
Not associated with rulemaking
  79 FR 77096 12/23/2014
80 FR 23640 04/28/2015
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 0 0 0 21,720
Annual Time Burden (Hours) 5,838 0 0 0 0 5,838
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$133,281
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.
05/18/2015