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Federal forms, ICRs, and supporting documents

Information Collection Request

VA Advance Directive - Durable Power of Attorney for Health Care and Living Will (VA Form 10-0137)

ICR 202010-2900-001 · OMB 2900-0556 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form 10-0137 VA Form 10-0137 Form and Instruction Modified Repair queued
30-day FRN_2900-0556_VA Advance Directive_POA for Health Care & Living Will_published 02122021.pdf Supplementary Document Uploaded 2021-02-18 Repair queued
60-day FRN_2900-0556_VA Advance Directive_POA for Health Care & Living Will_pub 100820.pdf Supplementary Document Uploaded 2020-11-28 Repair queued
2900-0556_Supp Stmnt A_VA Adv Directive_POA for Health Care & Living Will_updated Feb 2021.docx Supporting Statement A Uploaded 2021-02-18 Missing upstream
IC Document Collections
IC IDCollectionTypeStatusForm
242471 VA Form 10-0137 Form and Instruction Modified
241723 Close Personal Friend Statement of Relationship to Veteran Modified
ICR Details
2900-0556 202010-2900-001
Received in OIRA 202006-2900-009
VA 2900-0556
VA Advance Directive - Durable Power of Attorney for Health Care and Living Will (VA Form 10-0137)
Reinstatement with change of a previously approved collection   No
Regular 02/18/2021
  Requested Previously Approved
36 Months From Approved
343,922 0
171,861 0
0 0
Section 7331 of title 38, United States Code (U.S.C.), requires, in relevant part, that the Secretary of Veterans Affairs, upon the recommendation of the Under Secretary for Health, prescribe regulations to ensure, to the maximum extent practicable, that all VA patient care be carried out only with the full and informed consent of the patient, or in appropriate cases, a representative thereof. Based on VA’s interpretation of this statute and our mandate in 38 U.S.C. 7301(b) to provide a complete medical and hospital service, we recognize that patients with decision-making capacity have the right to state their treatment preferences in a VA or other valid advance directive. The VA advance directive form (both English and Spanish language versions) is VA Form 10-0137. These forms have a current OMB Paperwork Reduction Act (PRA) clearance under OMB Control Number 2900-0556. In addition, 2900-0556 now includes the collection of a “Close Personal Friend Statement” for incapacitated Veterans who have not completed an Advance Directive and are in need of health care. When a Veteran is incapacitated and does not have an Advance Directive, the VA regulations allow a statement to be submitted from a “Close Personal Friend” who will be responsible for making health care decisions on behalf of the Veteran. It is estimated that 300 such statements will be collected annually.
US Code: 38 USC 7331 Name of Law: Informed consent
  
None
Not associated with rulemaking
  85 FR 63661 10/08/2020
86 FR 9424 02/12/2021
No
  Total Request 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 343,922 0 0 0 0 343,922
Annual Time Burden (Hours) 171,861 0 0 0 0 171,861
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$6,379,342
No
    Yes
    Yes
No
No
No
No
Frances O'Donnell 703 405-2449 [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.
02/18/2021