Information Collection

VA Meds by Mail Order Form

IC 214210 under ICR 201412-2900-007 · OMB 2900-0832.

Documents and Forms

Document Name Document Type
Form 10-10068 VA Meds by Mail Order Form Form and Instruction
10-10068 VA meds by mail order form Final Draft CLFM Meds by Mail Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	VA Meds by Mail Order Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10068	VA meds by mail order form	Final Draft CLFM Meds by Mail Form.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 110,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	220,000	220,000
Annual IC Time Burden (Hours)	18,333	18,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.