Application for Extended Care Services, VA Form 10-10EC

OMB Control No: 2900-0629	ICR Reference No: 202107-2900-006
Status: Received in OIRA	Previous ICR Reference No: 201709-2900-015
Agency/Subagency: VA	Agency Tracking No: 2900-0629
Title: Application for Extended Care Services, VA Form 10-10EC
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 03/11/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	2,000	0
Time Burden (Hours)	3,000	0
Cost Burden (Dollars)	0	0

---

Abstract: Collects information to establish eligibility for extended care benefits, establishes financial liability veteran to pay if accepted for placement in Extended Care Services, and establishes veteran has agreed to make any applicable copayment.

---

Authorizing Statute(s): US Code: 38 USC 1710B Name of Law: Eligibility for hospital, nursing home, and domiciliary    US Code: 38 USC 1722A Name of Law: Determination of inability to defray necessary expenses;    US Code: 38 USC 1729 Name of Law: Recovery by the United States of the cost of certain    US Code: 38 USC 1705 Name of Law: Management of health care: patient enrollment system

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 73413	12/27/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 13371	03/09/2022
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title Form No. Form Name Application for Extended Care Services 10-10EC Application for Extended Care Benefits

---

ICR Summary of Burden

	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	2,000	0	0	0	0	2,000
Annual Time Burden (Hours)	3,000	0	0	0	0	3,000
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $52,345

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Frances O'Donnell 703 405-2449 [email protected]

---

Common Form ICR:  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:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(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;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
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.
Certification Date: 03/11/2022

---