[Federal Register Volume 69, Number 178 (Wednesday, September 15, 2004)]
[Notices]
[Pages 55660-55661]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-20743]


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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0188]


Agency Information Collection Activities Under OMB Review

AGENCY: Veterans Health Administration, Department of Veterans Affairs.

ACTION: Notice.

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SUMMARY: 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.

DATES: Comments must be submitted on or before October 15, 2004.

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 protected]. 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.

SUPPLEMENTARY INFORMATION:
    Title:
    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.

[[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.

    Dated: September 1, 2004.
    By direction of the Secretary.
Loise Russell,
Director, Records Management Service.
[FR Doc. 04-20743 Filed 9-14-04; 8:45 am]
BILLING CODE 8320-01-P