Agency Information Collection (Request for and Authorization To Release Medical Records or Health Information) Activities Under OMB Review, 64387-64388 [2012-25747]
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tkelley on DSK3SPTVN1PROD with NOTICES
Federal Register / Vol. 77, No. 203 / Friday, October 19, 2012 / Notices
g. Certification Regarding Lobbying,
VA Form 10–0144.
h. Statement of Assurance of
Compliance with Equal Opportunity
Laws, VA Form 10–0144a.
i. Request for Prescription Drugs from
an Eligible Veteran in a State Home, VA
Form 10–0460.
OMB Control Number: 2900–0160.
Type of Review: Extension of a
currently approved collection.
Abstract: VA pays per diem to State
homes providing nursing home and
adult day health services care to
Veterans. VA requires facilities
providing nursing home and adult day
health care to furnish an application for
recognition based on certification;
appeal information, application and
justification for payment; records and
reports which facility management must
maintain regarding activities of
residents or participants; information
relating to whether the facility meets
standards concerning residents’ rights
and responsibilities prior to admission
or enrollment, during admission or
enrollment, and upon discharge; the
records and reports which facilities
management and health care
professionals must maintain regarding
residents or participants and employees;
documents pertain to the management
of the facilities; food menu planning;
pharmaceutical records; and life safety
documentation. Without access to such
information, VA would not be able to
determine whether high quality care is
being provided to Veterans.
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 August
1, 2012, at pages 45719–45720.
Affected Public: State, Local or Tribal
Government.
Estimated Total Annual Burden:
a. Title 38, CFR Parts 51 and 52, State
Home Programs—3,738 hours.
b. State Home Inspection Staffing
Profile, VA Form 10–3567—90 hours.
c. State Home Report and Statement
of Federal Aid Claimed, VA Form 10–
5588—1,080 hours.
d. State Home Program Application
for Veteran Care—Medical Certification,
VA Form 10–10SH—10,566 hours.
e. Department of Veterans Affairs
Certification Regarding Drug-Free
Workplace Requirements for Grantees
Other Than Individuals, VA Form 10–
0143—15 hours.
f. Statement of Assurance of
Compliance with Section 504 of the
VerDate Mar<15>2010
16:06 Oct 18, 2012
Jkt 229001
Rehabilitation Act of 1973, VA Form
10–1043a—15 hours.
g. Certification Regarding Lobbying,
VA Form 10–0144—15 hours.
h. Statement of Assurance of
Compliance with Equal Opportunity
Laws, VA Form 10–0144a—15 hours.
i. Request for Prescription Drugs from
an Eligible Veteran in a State Home, VA
Form 10–0460—15 hours.
Estimated Average Burden per
Respondent:
a. Title 38, CFR Parts 51 and 52, State
Home Programs—7 minutes.
b. State Home Inspection Staffing
Profile, VA Form 10–3567—30 minutes.
c. State Home Report and Statement
of Federal Aid Claimed, VA Form 10–
5588—30 minutes.
d. State Home Program Application
for Veteran Care—Medical Certification,
VA Form 10–10SH—30 minutes.
e. Department of Veterans Affairs
Certification Regarding Drug-Free
Workplace Requirements for Grantees
Other Than Individuals, VA Form 10–
0143—5 minutes.
f. Statement of Assurance of
Compliance with Section 504 of the
Rehabilitation Act of 1973, VA Form
10–1043a—5 minutes.
g. Certification Regarding Lobbying,
VA Form 10–0144—5 minutes.
h. Statement of Assurance of
Compliance with Equal Opportunity
Laws, VA Form 10–0144a—5 minutes.
i. Request for Prescription Drugs from
an Eligible Veteran in a State Home, VA
Form 10–0460—5 minutes.
Frequency of Response: One-time.
Estimated Number of Respondents:
a. Title 38, CFR Parts 51 and 52, State
Home Programs—22,926.
b. State Home Inspection Staffing
Profile, VA Form 10–3567—180.
c. State Home Report and Statement
of Federal Aid Claimed, VA Form 10–
5588—180.
d. State Home Program Application
for Veteran Care—Medical Certification,
VA Form 10–10SH—21,132.
e. Department of Veterans Affairs
Certification Regarding Drug-Free
Workplace Requirements for Grantees
Other Than Individuals, VA Form 10–
0143—180.
f. Statement of Assurance of
Compliance with Section 504 of the
Rehabilitation Act of 1973, VA Form
10–1043a—180.
g. Certification Regarding Lobbying,
VA Form 10–0144—180.
h. Statement of Assurance of
Compliance with Equal Opportunity
Laws, VA Form 10–0144a—180.
i. Request for Prescription Drugs from
an Eligible Veteran in a State Home, VA
Form 10–0460—180.
Estimated Total Annual Responses:
PO 00000
Frm 00079
Fmt 4703
Sfmt 4703
64387
a. Title 38, CFR Parts 51 and 52, State
Home Programs—23,466
b. State Home Inspection Staffing
Profile, VA Form 10–3567—180.
c. State Home Report and State of
Federal Aid Claimed, VA Form 10–
5588—2,160.
d. State Home Program Application
for Veteran Care—Medical Certification,
VA Form 10–10SH—21,132.
e. Department of Veterans Affairs
Certification Regarding Drug-Free
Workplace Requirements for Grantees
Other Than Individuals, VA Form 10–
0143—180.
f. Statement of Assurance of
Compliance with Section 504 of the
Rehabilitation Act of 1973, VA Form
10–1043a—180.
g. Certification Regarding Lobbying,
VA Form 10–0144—180.
h. Statement of Assurance of
Compliance with Equal Opportunity
Laws, VA Form 10–0144a—180.
i. Request for Prescription Drugs from
an Eligible Veteran in a State Home, VA
Form 10–0460—180.
Dated: October 15, 2012.
By direction of the Secretary.
William F. Russo,
Deputy Director, Office of Regulations Policy
and Management, Office of the General
Counsel, Department of Veterans Affairs.
[FR Doc. 2012–25749 Filed 10–18–12; 8:45 am]
BILLING CODE 8320–01–P
DEPARTMENT OF VETERANS
AFFAIRS
[OMB Control No. 2900–0260]
Agency Information Collection
(Request for and Authorization To
Release Medical Records or Health
Information) Activities Under OMB
Review
Veterans Health
Administration, Department of Veterans
Affairs.
ACTION: Notice.
AGENCY:
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.
SUMMARY:
Comments must be submitted on
or before November 19, 2012.
DATES:
E:\FR\FM\19OCN1.SGM
19OCN1
64388
Federal Register / Vol. 77, No. 203 / Friday, October 19, 2012 / Notices
Submit written comments
on the collection of information through
www.Regulations.gov; or 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–
0260’’ in any correspondence.
FOR FURTHER INFORMATION CONTACT:
Crystal Rennie, Enterprise Records
Service (005R1B), Department of
Veterans Affairs, 810 Vermont Avenue
NW., Washington, DC 20420, (202) 632–
7492, fax (202) 632–7583 or email
crystal.rennie@va.gov. Please refer to
‘‘OMB Control No. 2900–0260.’’
SUPPLEMENTARY INFORMATION:
Titles:
a. Request for and Authorization to
Release Medical Records or Health
Information, VA Form 10–5345.
b. Individual’s Request for a Copy of
their Own Health Information, VA Form
10–5345a.
c. My HealtheVet (MHV)—
Individuals’ Request for a Copy of Their
Own Health Information, VA Form 10–
5345a–MHV.
d. Restriction of the Release of
Individually-Identifiable Health
Information through Nationwide Health
Information Network (NwHIN), VA
Form 10–0525a.
e. Request for and Authorization to
Release Protected Health Information to
Nationwide Health Information
Network, VA Form 10–0485.
OMB Control Number: 2900–0260.
Type of Review: Revision of a
currently approved collection.
Abstracts:
a. VA Form 10–5345 is used to obtain
a written consent from patients before
information concerning his or her
treatment for alcoholism or alcohol
abuse, drug abuse, sickle cell anemia, or
infection with the human
immunodeficiency virus (HIV) can be
disclosed to private insurance
companies, physicians and other third
parties.
b. Patients complete VA Form 10–
5345a to request a copy of their health
information maintained at Department
of Veterans Affairs.
c. VA Form 10–5345a–MHV is
completed by individuals requesting
their health information electronically
through My HealtheVet.
d. VA Form 10–0525a is completed by
individuals to restrict the sharing their
electronic health information through
the NWHIN.
e. VA Form 10–0485 is used to
electronically exchange protected health
information between VA and approved
Nationwide Health Information Network
participants.
tkelley on DSK3SPTVN1PROD with NOTICES
ADDRESSES:
VerDate Mar<15>2010
16:06 Oct 18, 2012
Jkt 229001
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 July
19, 2012 at pages 42555–42556.
Affected Public: Individuals or
households.
Estimated Total Annual Burden
a. VA Form 10–5345—10,000 hours.
b. VA Form 10–5345a—15,000 hours.
c. VA Form 10–5345a—MVH–35,000
hours.
d. VA Form 10–0525a—50 hours.
e. VA Form 10–0485—500 hours.
Estimated Average Burden per
Respondent—2 minutes for VA Form
10–5345 and 3 minutes for VA Forms
10–5345a, 10–5345a–MVH, 10–0525a,
10–0485.
Frequency of Response: On occasion.
Estimated Number of Respondents:
a. VA Form 10–5345—300,000.
b. VA Form 10–5345a—300,000.
c. 10–5345a–MVH—700,000.
d. VA Form 10–0525a—1,000.
e. VA Form 10–0485—10,000.
Dated: October 15, 2012.
By direction of the Secretary.
William F. Russo,
Deputy Director, Office of Regulations Policy
and Management, Office of the General
Counsel, Department of Veterans Affairs.
[FR Doc. 2012–25747 Filed 10–18–12; 8:45 am]
BILLING CODE 8320–01–P
DEPARTMENT OF VETERANS
AFFAIRS
[OMB Control No. 2900–0427]
Agency Information Collection (Former
POW Medical History), VA Form 10–
0048 Activities Under OMB Review
Veterans Health
Administration, Department of Veterans
Affairs.
ACTION: Notice.
AGENCY:
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.
DATES: Comments must be submitted on
or before November 19, 2012.
SUMMARY:
PO 00000
Frm 00080
Fmt 4703
Sfmt 9990
Submit written comments
on the collection of information through
www.Regulations.gov; or 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–
0427’’ in any correspondence.
ADDRESSES:
FOR FURTHER INFORMATION CONTACT:
Crystal Rennie, Enterprise Records
Service (005R1B), Department of
Veterans Affairs, 810 Vermont Avenue
NW., Washington, DC 20420, (202) 632–
7492, fax (202) 632–7583 or email
crystal.rennie@va.gov. Please refer to
‘‘OMB Control No. 2900–0427.’’
SUPPLEMENTARY INFORMATION:
Title: Former POW Medical History,
VA Form 10–0048.
OMB Control Number: 2900–0427.
Type of Review: Extension of a
currently approved collection.
Abstract: VA Form 10–0048 is
completed by a VA physician during a
medical examination of a Former
Prisoner of War veteran. VA will use the
data collected as a guide and reference
for treatment planning for the FPOW
veteran.
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 August
1, 2012, at page 45717.
Affected Public: Individuals or
households.
Estimated Total Annual Burden: 113
hours.
Estimated Average Burden per
Respondent: 90 minutes.
Frequency of Response: One time.
Estimated Number of Respondents:
75.
Dated: October 15, 2012.
By direction of the Secretary.
William F. Russo,
Deputy Director, Office of Regulations Policy
and Management, Office of the General
Counsel, Department of Veterans Affairs.
[FR Doc. 2012–25757 Filed 10–18–12; 8:45 am]
BILLING CODE 8320–01–P
E:\FR\FM\19OCN1.SGM
19OCN1
]]>Agencies
[Federal Register Volume 77, Number 203 (Friday, October 19, 2012)]
[Notices]
[Pages 64387-64388]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-25747]
-----------------------------------------------------------------------
DEPARTMENT OF VETERANS AFFAIRS
[OMB Control No. 2900-0260]
Agency Information Collection (Request for and Authorization To
Release Medical Records or Health Information) Activities Under OMB
Review
AGENCY: Veterans Health Administration, Department of Veterans Affairs.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: 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.
DATES: Comments must be submitted on or before November 19, 2012.
[[Page 64388]]
ADDRESSES: Submit written comments on the collection of information
through www.Regulations.gov; or 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. 2900-0260'' in any correspondence.
FOR FURTHER INFORMATION CONTACT: Crystal Rennie, Enterprise Records
Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue
NW., Washington, DC 20420, (202) 632-7492, fax (202) 632-7583 or email
crystal.rennie@va.gov. Please refer to ``OMB Control No. 2900-0260.''
SUPPLEMENTARY INFORMATION:
Titles:
a. Request for and Authorization to Release Medical Records or
Health Information, VA Form 10-5345.
b. Individual's Request for a Copy of their Own Health Information,
VA Form 10-5345a.
c. My HealtheVet (MHV)--Individuals' Request for a Copy of Their
Own Health Information, VA Form 10-5345a-MHV.
d. Restriction of the Release of Individually-Identifiable Health
Information through Nationwide Health Information Network (NwHIN), VA
Form 10-0525a.
e. Request for and Authorization to Release Protected Health
Information to Nationwide Health Information Network, VA Form 10-0485.
OMB Control Number: 2900-0260.
Type of Review: Revision of a currently approved collection.
Abstracts:
a. VA Form 10-5345 is used to obtain a written consent from
patients before information concerning his or her treatment for
alcoholism or alcohol abuse, drug abuse, sickle cell anemia, or
infection with the human immunodeficiency virus (HIV) can be disclosed
to private insurance companies, physicians and other third parties.
b. Patients complete VA Form 10-5345a to request a copy of their
health information maintained at Department of Veterans Affairs.
c. VA Form 10-5345a-MHV is completed by individuals requesting
their health information electronically through My HealtheVet.
d. VA Form 10-0525a is completed by individuals to restrict the
sharing their electronic health information through the NWHIN.
e. VA Form 10-0485 is used to electronically exchange protected
health information between VA and approved Nationwide Health
Information Network participants.
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 July 19, 2012 at pages 42555-42556.
Affected Public: Individuals or households.
Estimated Total Annual Burden
a. VA Form 10-5345--10,000 hours.
b. VA Form 10-5345a--15,000 hours.
c. VA Form 10-5345a--MVH-35,000 hours.
d. VA Form 10-0525a--50 hours.
e. VA Form 10-0485--500 hours.
Estimated Average Burden per Respondent--2 minutes for VA Form 10-
5345 and 3 minutes for VA Forms 10-5345a, 10-5345a-MVH, 10-0525a, 10-
0485.
Frequency of Response: On occasion.
Estimated Number of Respondents:
a. VA Form 10-5345--300,000.
b. VA Form 10-5345a--300,000.
c. 10-5345a-MVH--700,000.
d. VA Form 10-0525a--1,000.
e. VA Form 10-0485--10,000.
Dated: October 15, 2012.
By direction of the Secretary.
William F. Russo,
Deputy Director, Office of Regulations Policy and Management, Office of
the General Counsel, Department of Veterans Affairs.
[FR Doc. 2012-25747 Filed 10-18-12; 8:45 am]
BILLING CODE 8320-01-P
