Information Collection

Preliminary Independent Living (IL) Assessment

IC 44130 under ICR 201412-2900-010 · OMB 2900-0681.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0681 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 28-0791 Preliminary Independent Living (IL) Assessment Form
VA Form 28-0791 Preliminary Independent Living (IL) Assessment 28-0791(1-15).pdf www.va.gov/vaforms Form
VA Form 28-8739a Protection of Privacy Information Statement 28-8739a.pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Preliminary Independent Living (IL) Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 21.50 38 CFR 21.160 38 CFR 21.162

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 28-0791	Preliminary Independent Living (IL) Assessment	28-0791(1-15).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 28-8739a	Protection of Privacy Information Statement	28-8739a.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,500	2,500
Annual IC Time Burden (Hours)	2,500	2,500
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.