Environmental Hazards Registry (EHR) Worksheet (VA Form 10-10176)

Forms and Documents

Document Name	Status
Form 10-10176 Environmental Hazards Registry (EHR) Worksheet for Veterans Form	New
30-day FRN_EHR Worksheet_published_120919.pdf Supplementary Document	2020-07-17
60-day FRN_EHR Worksheet_published_081919.pdf Supplementary Document	2019-11-21
EHR Worksheet for Veterans_Supporting Statement A_ revised 2020.docx Supporting Statement A	2020-07-17

IC Document Collections

IC ID	Document Title	Status
236782	Environmental Hazards Registry (EHR) Worksheet for Veterans Form	New

ICR Details

OMB Control No:	ICR Reference No: 201907-2900-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: 2900-NEW
Title: Environmental Hazards Registry (EHR) Worksheet (VA Form 10-10176)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/17/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	20,000	0
Time Burden (Hours)	20,000	0
Cost Burden (Dollars)	0	0

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Abstract: Legal authority for this data collection is found under the following Congressional mandates that authorize the collection of data that will allow measurement and evaluation of the Department of Veterans Affairs Programs, the goal of which is improved health care for Veterans. • Agent Orange Registry: Public Laws 102-4, 102-585 Section 703,100-687 and 38 United States Code (U.S.C.) 527, 38 U.S.C. 1116. • Gulf War Registry: Public Laws 102-585, 103-446 and 38 U.S.C. 1117. • Ionizing Radiation: Public Laws 102-585 Section 703, 100-687 and 38 U.S.C. 527, 38 U.S.C. 1116. The new Environmental Health Registry (EHR) Worksheet, VA Form 10-10176, supersedes VA Form 10-9009 (June 2005), VA Form 10-9009A (March 2010) and VA Form 10-0020A (June 2005). Post Deployment Health Services (PDHS) plans to have this form electronically accessible to Environmental Health Coordinators and Clinicians once the EHR is in place. Until then, PDHS requests to consolidate 3 existing forms into one comprehensive form. Currently, VA is exploring the performance of limited registry examinations via telemedicine, in order to reduce Veterans’ need to travel and potentially reduce waiting times for exams. The form information would be the same, and otherwise the process to collect and put data into the registry database will not change. Once the exam template is available, it can be used to import information more seamlessly into the Veteran patient record. VA Environmental Health Registry evaluations are free, voluntary medical assessments for Veterans who may have been exposed to certain environmental hazards during military service. Evaluations alert Veterans to possible long-term health problems that may be related to exposure specific to environmental hazards during their military service. The registry data may help VA understand and respond to these health problems more effectively and may be useful for research purposes. Application can be made by VA researchers to use the data under strict Institutional Review Board control.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 42993	08/19/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 67339	12/09/2019
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Environmental Hazards Registry (EHR) Worksheet for Veterans	10-10176	Environmental Hazards Registry (EHR) Worksheet for Veterans

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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	20,000	0	0	20,000	0	0
Annual Time Burden (Hours)	20,000	0	0	20,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new information collection, and all burden hours would normally be considered a program increase. However, this new form consolidates and eliminates three existing forms: VA Form 10-9009, June 2005; VA Form 10-9009A, March 2010; and VA Form 10-0020A, June 2005. Therefore, the burden hours are reduced from filling out three forms to filling out just one form (worksheet).

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Annual Cost to Federal Government: $4,000

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

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Common Form ICR:  No

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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: 07/17/2020

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