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Federal forms, ICRs, and supporting documents

Information Collection Request

Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)

ICR 201602-2900-005 · OMB 2900-0652 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 21-0779 Request for Nursing Home Information in Connection with Claim for Aid and Attendance Form Modified Available
2016-20364, 30-Day FRN, 2900-0652 (21-0779).pdf Supplementary Document Uploaded 2016-09-27 Available
2900-0652 VAF21-0779 SS.docx Supporting Statement A Uploaded 2016-09-27 Repair queued
2016-13391, 60-Day FRN, VAF21-0779.pdf Supplementary Document Uploaded 2016-06-09 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28927 Request for Nursing Home Information in Connection with Claim for Aid and Attendance Form Modified
ICR Details
2900-0652 201602-2900-005
Historical Active 201304-2900-024
VA VBA-COMP-NK
Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)
Revision of a currently approved collection   No
Regular
Approved without change 02/17/2017
Retrieve Notice of Action (NOA) 09/30/2016
  Inventory as of this Action Requested Previously Approved
02/29/2020 36 Months From Approved 02/28/2017
61,125 0 50,000
10,188 0 8,333
201,519 0 0
VA Form 21-0779 is used to gather the necessary information to determine eligibility for pension and aid and attendance based on being in a nursing home. This form also requests information on Medicaid status and nursing home care charges, so VA can determine the proper rate of payment.
US Code: 38 USC 1502 Name of Law: Determination with respect to disability
   US Code: 38 USC 1115(1)(E) Name of Law: Aid and attendance
   US Code: 38 USC 1311(c) Name of Law: Dependency and indemnity compensation to a surviving spouse
   US Code: 38 USC 1315(h) Name of Law: Dependency and Indemnity compensation to parents
   US Code: 38 USC 5503 Name of Law: Hospitalized veterans and estates of incompetent institutionalized veterans
   US Code: 38 USC 501(a)(2) Name of Law: Rules and regulations
  
None
Not associated with rulemaking
  81 FR 109 06/07/2016
81 FR 165 08/25/2016
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 61,125 50,000 0 11,125 0 0
Annual Time Burden (Hours) 10,188 8,333 0 1,855 0 0
Annual Cost Burden (Dollars) 201,519 0 0 201,519 0 0
Yes
Miscellaneous Actions
No
The respondent burden hours per response have not changed (10 minutes or 0.16667 hours). VBA re-evaluated the number of these application forms received per year, and increased the estimated number of responses from 50,000 to 61,125. The evaluation was based on actual claims data contained in VBA’s benefits database.
$3,276,856
No
No
No
No
No
Uncollected
Cynthia Harvey - Pryor 202 461-5870 [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.
09/30/2016