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Agency Information Collection (Claims, Authorization, and Invoice for Prosthetic Items and Services) Activities Under OMB Review

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Veterans Health Administration, Department of Veterans Affairs.




In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-3521), this notice announces that the Veterans Health Administration (VHA), Department of Veterans Affairs, will submit 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.


Written comments and recommendations on the proposed collection of information should be received on or before August 4, 2014.


Submit written comments on the collection of information through, or to Office of Information and Regulatory Affairs, Office of Management and Budget, Attn: VA Desk Officer; 725 17th St. NW., Washington, DC 20503 or sent through electronic mail to Please refer to “OMB Control No. 2900-0188 (Claims, Authorization, and Invoice for Prosthetic items and Services)” in any correspondence. During the comment period, comments may be viewed online through the FDMS.

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Crystal Rennie, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, (202) 632-7492 or email Please refer to “OMB Control No. 2900-NEW (Veterans, Researchers, and IRB Members Experiences with Recruitment Restrictions)” in any correspondence.

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Under the PRA of 1995 (Pub. L. 104-13; 44 U.S.C. 3501—3521), 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 Start Printed Page 38128comments 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.



1. Veterans Application for Assistance in Acquiring Home Improvement and Structural Alterations, VA Form 10-0103.

2. Application for Adaptive Equipment for Motor Vehicle, VA Form 10-1394.

3. Prosthetic Authorization for Items or Services, VA Form 10-2421.

4. Request to Submit Quotation, VA Form Fl-10-90.

5. Prescription Authorization for Glasses, VA Form 10-2914.

6. Prosthetic Service Card Invoice, VA Form 10-2520.

Type of Review: Revision of a currently approved collection.


a. VA Form 10-0103, Veterans Application for Assistance in Acquiring Home Improvement and Structural Alterations (HISA) grants, is used by the Prosthetic Service to determine eligibility/entitlement and reimbursement of individual claims for home improvement and structural alterations.

b. VA Form 10-1394, Application for Adaptive Equipment Motor Vehicle. This form is used by VHA Prosthetic Service, Fiscal Service and Veterans Benefits Administration to determine eligibility/entitlement and reimbursement of individual claims for automotive adaptive equipment.

c. VA Form 10-2421, Prosthetic Authorization for Items or Services, is used for the direct procurement of new prosthetic appliances and/or services by PSAS (Prosthetic and Sensory Aids Service) under the COCP (Contracting Officers Certification Program). Warrants to PSAS personnel are authorized for open market and Federal Supply Schedule purchases, and decentralized and local beneficiary service contracts.

d. VA Form 10-2520, Prosthetic Service Card Invoice, is used by the vendor as an invoice and billing document.

e. VA Form 10-2914, Prescription and Authorization for Fee Basis Eyeglasses, is used as a combination prescription, authorization and invoice. It purchases eyeglasses directly for veterans.

f. Form Letter 10-90, Request to Submit Quotation, is used by the VAMC Prosthetics Service to request a quotation for items listed.

g. Affected Public: Individuals or households.

Estimated Annual Burden:

a. VA Form 10-0103- 583 hours.

b. VA Form 10-01394—1,000 hours.

c. VA Form 10-2421—67 hours.

d. VA Form 10-2520—47 hours.

e. VA Form 10-2914—3,333 hours.

f. VA Form Letter 10-90—708 hours.

Estimated Average Burden Per Respondent:

a. VA Form 10-0103—5 minutes.

b. VA Form 10-1394 -15 minutes

c. VA Form 10-2421—4 minutes.

d. VA Form 10-2520—4 minutes.

e. VA Form 10-2914—4 minutes.

f. VA Form Letter 10-90—5 minutes.

Frequency of Response: Annually.

Estimated Annual Responses:

a. VA Form 10-0103—7,000.

b. VA Form 10-1394—4,000.

c. VA Form 10-2421—1,000.

d. VA Form 10-2520—700.

e. VA Form 10-2914—50,000.

f. VA Form Letter 10-90—8,500.

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Dated: June 27, 2014.

By direction of the Secretary.

Crystal Rennie,

VA Clearance Officer, U.S. Department of Veterans Affairs.

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[FR Doc. 2014-15550 Filed 7-2-14; 8:45 am]