Per Diem to States for Care of Eligible Veterans in State Homes

Forms and Documents

Document Name	Status
Form 10-3567 State Home Inspection Staffing Profile Form and Instruction	New
Form 10-0460 Request for Prescription Drugs from an Eligible Veteran in a State Home Form	New
Form 10-0144A Statement of Assurance of Compliance with Equal Opportunity Laws Form	New
Form 10-0144 Certification Regarding Lobbying Form	New
Form 10-0143A Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973 Form	New
Form 10-0143 Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals Form	New
30-day FRN_Per Diem to States for Care of Eligible Veterans in State Homes_published 100419.pdf Supplementary Document	2020-05-19
60-day FRN_Per Diem to States for Care of Eligible Veterans in State Homes_published 072319.pdf Supplementary Document	2020-05-19
Per Diem to States for Veteran Care in State Homes_Supp Statement A_revised Mar 2020.docx Supporting Statement A	2020-05-19

IC Document Collections

IC ID	Document Title	Status
242721	State Home Inspection Staffing Profile Form and Instruction	New
242720	Request for Prescription Drugs from an Eligible Veteran in a State Home Form	New
242719	Statement of Assurance of Compliance with Equal Opportunity Laws Form	New
242717	Certification Regarding Lobbying Form	New
242714	Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973 Form	New
241862	Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals Form	New

ICR Details

OMB Control No: 2900-0883	ICR Reference No: 202005-2900-011
Status: Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: 2900-NEW
Title: Per Diem to States for Care of Eligible Veterans in State Homes
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/02/2020
	Date Received in OIRA: 07/22/2020
Terms of Clearance: In its next revision, extension, or reinstatement request, VA shall ensure all forms in this collection display the information required by 5 CFR 1320.8(b)(3)(v).

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2023	36 Months From Approved
Responses	11,780	0	0
Time Burden (Hours)	5,630	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The circumstances making this collection of forms necessary for providing information to the VA are from Title 38 CFR Part 51 State Veterans Homes (SVH) regulations published in the Federal Register as final rule on November 28, 2018 (RIN 2900-A088). This collection of forms was part of a previously approved collection under OMB Control Number 2900-0160. However, it has been determined that these six forms will be separated from the other three forms in 2900-0160, and this ICR seeks renewal under a new OMB Control Number. These six forms are presented to and completed by SVH management and then assessed and utilized by VA SVH Representatives designated by the Medical Center Director of VA of jurisdiction during the annual VA survey process at each SVH across the U.S. as a regulatory action. This collection of forms falls under the auspices of Geriatrics and Extended Care in VA Central Office (10NC4). As per VHA Directive 1145.01, this collection of forms is part of the annual VA survey process. The legal requirements that necessitate this collection of information are found specifically at 38 CFR Parts 51.31, 51.43, and 51.210 for all three levels of care; nursing home, domiciliary, and adult day health care.

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Authorizing Statute(s): PL: Pub.L. 109 - 461 211(a)(5) Name of Law: Veterans Benefits, Health Care, and Information Technology - Modification to State Home Authorities
  

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 35453	07/23/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 53243	10/04/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973	10-0143A	Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973
Certification Regarding Lobbying	10-0144	Certification Regarding Lobbying
Statement of Assurance of Compliance with Equal Opportunity Laws	10-0144A	Statement of Assurance of Compliance with Equal Opportunity Laws
Request for Prescription Drugs from an Eligible Veteran in a State Home	10-0460	Request for Prescription Drugs from an Eligible Veteran in a State Home
State Home Inspection Staffing Profile	10-3567	State Home Inspection Staffing Profile
Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals	10-0143	Department of Veterans Affairs Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals

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ICR Summary of Burden

	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	11,780	0	0	11,780	0	0
Annual Time Burden (Hours)	5,630	0	0	5,630	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 collection of forms was part of a previously approved collection under OMB Control Number 2900-0160. However, it has been determined that these six forms will be separated from the other three forms in 2900-0160, and this ICR seeks renewal under a new OMB Control Number. Therefore, this is presented as a 'new' collection and all burden numbers constitute an increase.

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Annual Cost to Federal Government: $97,760

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: 07/22/2020

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