SUPPLEMENTARY INFORMATION:

Under the PRA of 1995, Federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. This request for comment is being made pursuant to Section 3506(c)(2)(A) of the PRA.

With respect to the following collection of information, VHA invites comments on: (1) whether the proposed collection of information is necessary for the proper performance of VHA's functions, including whether the information will have practical utility; (2) the accuracy of VHA's estimate of the burden of the proposed collection of information; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) ways to minimize the burden of the collection of information on respondents, including through the use of automated collection techniques or the use of other forms of information technology.

Title: Per Diem to States for Care of Eligible Veterans in State Homes (VA Forms 10-0143, 10-0143A, 10-0144, 10-0144A, 10-0460, and 10-3567).

OMB Control Number: 2900-0883.www.reginfo.gov/​public/​do/​PRASearch (Once at this link, you can enter the OMB Control Number to find the historical versions of this Information Collection).

Type of Review: Revision of a currently approved collection.

Abstract: Authority for this information collection is found in Title 38 Code of Federal Regulations (CFR) Part 51, “Per Diem for Nursing Home, Domiciliary or Adult Day Health Care of Veterans in State Veterans Homes.” Specifically, the legal requirements that necessitate this collection of information are found in Title 38 CFR Parts § 51.31, § 51.43 and § 51.210 for all three levels of care: nursing home, domiciliary, and adult day health care. VA requires State Veterans Homes (SVHs) to be recognized by the Under Secretary for Health as providing safe, high-quality programs in these areas.

The six forms in this collection (10-0143, 10-0143A, 10-0144, 10-0144A, 10-0460 and 10-3567) are completed by SVH management as part of the VA survey process and ongoing compliance. This information collection falls under the auspices of the Office of Geriatrics and Extended Care in VA Central Office (12GEC). The information is assessed in accordance with the applicable regulations by VA contracted vendors during a VA survey at each SVH.

a. VA Form 10-0143 is used for annual certification pursuant to the Drug-Free Workplace Act of 1988.

b. VA Form 10-0143A is used for annual certification of compliance with Section 504 of the Rehabilitation Act of 1973 (Pub. L. 93-112).

c. VA Form 10-0144 is used for annual certification regarding lobbying, in compliance with Public Law 101-121.

d. VA Form 10-0144A is used for annual certification of compliance with Title VI of the Civil Rights Act of 1964, as incorporated in Title 38 CFR 18.1-18.3.

e. VA Form 10-0460 is used for the SVH to submit to the VA medical center of jurisdiction a monthly itemization of the corresponding prescription(s) for each eligible Veteran.

f. VA Form 10-3567 is completed by SVH management for the annual VA survey and is used by VA to record and then assess the following: operating beds versus recognized beds, total full-time employee equivalent (FTEE) authorized and total FTEE available, and resident census.

Total Annual Burden: 2,248 hours.

Total Annual Responses: 2,975.

VA Form 10-0143

Affected Public: State, Local, and Tribal Governments.

Estimated Annual Burden: 15 hours.

Estimated Average Burden per Respondent: 5 minutes.

Frequency of Response: Once annually.

Estimated Number of Respondents: 175.

VA Form 10-0143A

Affected Public: State, Local, and Tribal Governments.

Estimated Annual Burden: 15 hours.

Estimated Average Burden per Respondent: 5 minutes.

Frequency of Response: Once annually.

Estimated Number of Respondents: 175.

VA Form 10-0144

Affected Public: State, Local, and Tribal Governments.

Estimated Annual Burden: 15 hours.

Estimated Average Burden per Respondent: 5 minutes.

Frequency of Response: Once annually.

Estimated Number of Respondents: 175.

VA Form 10-0144A

Affected Public: State, Local, and Tribal Governments.

Estimated Annual Burden: 15 hours.

Estimated Average Burden per Respondent: 5 minutes.

Frequency of Response: Once annually.

Estimated Number of Respondents: 175.

VA Form 10-0460

Affected Public: State, Local, and Tribal Governments.

Estimated Annual Burden: 2,100 hours.

Estimated Average Burden per Respondent: 60 minutes.

Frequency of Response: 12 times per year.

Estimated Number of Respondents: 175.

VA Form 10-3567

Affected Public: State, Local, and Tribal Governments.

Estimated Annual Burden: 88 hours.

Estimated Average Burden per Respondent: 30 minutes.

Frequency of Response: Once annually.

Estimated Number of Respondents: 175.

( printed page 66202)

(Authority: 44 U.S.C. 3501 et seq.)