Veterans Health Administration, Department of Veterans Affairs.
In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-21), this notice announces that the Veterans Health Administration (VHA), Department of Veterans Affairs, has submitted the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden and includes the actual data collection instrument.
Comments must be submitted on or before October 15, 2004.Start Further Info
FOR FURTHER INFORMATION OR A COPY OF THE SUBMISSION CONTACT:
Denise McLamb, Records Management Service (005E3), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 273-8030, fax (202) 273-5981 or e-mail to: email@example.com. Please refer to “OMB Control No. 2900-0188.”
Send comments and recommendations concerning any aspect of the information collection to VA's OMB Desk Officer, OMB Human Resources and Housing Branch, New Executive Office Building, Room 10235, Washington, DC 20503, (202) 395-7316. Please refer to “OMB Control No. 2900-0188” in any correspondence.End Further Info End Preamble Start Supplemental Information
a. Request to Submit Estimate, Form Letter 10-90.
b. Loan Follow-up Letter, Form Letter 10-426.
c. Veterans Application for Assistance in Acquiring Home Improvement and Structural Alterations, VA Form 10-0103.
d. Application for Adaptive Equipment Motor Vehicle, VA Form 10-1394.
e. Prosthetic Authorization for Items or Services, VA Form 10-2421.
f. Prosthetic Service Card Invoice, VA Form 10-2520.
g. Prescription and Authorization for Eyeglasses, VA Form 10-2914.
OMB Control Number: 2900-0188.
Type of Review: Extension of a currently approved collection.
Abstract: The following forms will be used to determine eligibility, prescribe, authorize prosthetic devices, and obtain follow-up information on loaned prosthetic items, glasses, and adaptation to house and automobile:
a. VA Form Letter 10-90 is used to obtain estimated price for prosthetic devices.
b. Form Letter 10-426 is used to inventory prosthetic devices loaned to eligible veterans. The form letter inventories the loaned items and solicits information from the beneficiary to determine the current status, the need to replace, extend the loan period or terminate the loaned items. Start Printed Page 55661
c. VA Form 10-0103 is used to determine eligibility/entitlement and reimbursement of individual claims for home improvement and structural alterations.
d. VA Form 10-1394 is used to determine eligibility/entitlement and reimbursement of individual claims for automotive adaptive equipment.
e. VA Form 10-2421 is used for the direct procurement of new prosthetic appliances and/or services. The form standardizes the direct procurement authorization process, eliminating the need for separate purchase orders, expedites patient treatment and improves the delivery of prosthetic services.
f. VA Form 10-2520 is used by the vendors as an invoice and billing document. The form standardizes repair/treatment invoices for prosthetic services rendered and standardizes the verification of these invoices. The veteran certifies that the repairs were necessary and satisfactory. This form is furnished to vendors upon request.
g. VA Form 10-2914 is used as a combination prescription, authorization and invoice. It allows veterans to purchase their eyeglasses directly. If the form is not used, the provisions of providing eyeglasses to eligible veterans may be delayed.
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published on June 8, 2004, at page 32098.
Affected Public: Individuals or households and business or other for profit.
Estimated Total Annual Burden: 48,522 hours.
a. Form Letter 10-90—708.
b. Form Letter 10-426—17.
c. VA Form 10-0103—583.
d. VA Form 10-1394—2,500.
e. VA Form 10-2421—4,667.
f. VA Form 10-2520—47.
g. VA Form 10-2914—40,000.
Estimated Average Burden Per Respondent:
a. Form Letter 10-90—5 minutes.
b. Form Letter 10-426—1 minute.
c. VA Form 10-0103—5 minutes.
d. VA Form 10-1394—15 minutes.
e. VA Form 10-2421—4 minutes.
f. VA Form 10-2520—4 minutes.
g. VA Form 10-2914—4 minutes.
Frequency of Response: On occasion.
Estimated Number of Respondents: 697,200.
a. Form Letter 10-90—8,500.
b. Form Letter 10-426—1,000.
c. VA Form 10-0103—7,000.
d. VA Form 10-1394—10,000.
e. VA Form 10-2421—70,000.
f. VA Form 10-2520—700.
g. VA Form 10-2914—600,000.Start Signature
Dated: September 1, 2004.
By direction of the Secretary.
Director, Records Management Service.
[FR Doc. 04-20743 Filed 9-14-04; 8:45 am]
BILLING CODE 8320-01-P