25320 Federal Register / Vol. 75, No. 88 / Friday, May 7, 2010 / Notices 

DEPARTMENT OF VETERANS 

AFFAIRS 

[OMB Control No. 2900–0219] 

Agency Information Collection 

(Application for CHAMPVA Benefits) 

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. 3501–21), 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. 

DATE: Comments must be submitted on 

or before June 7, 2010. 

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– 

0219’’ in any correspondence. 

FOR FURTHER INFORMATION CONTACT: 

Denise McLamb, Enterprise Records 

Service (005R1B), Department of 

Veterans Affairs, 810 Vermont Avenue, 

NW., Washington, DC 20420, (202) 461– 

7485, fax (202) 273–0443 or e-mail 

denise.mclamb@va.gov. Please refer to 

‘‘OMB Control No. 2900–0219.’’ 

SUPPLEMENTARY INFORMATION: 

Titles: 

a. Application for CHAMPVA 

Benefits, VA Form 10–10d. 

b. CHAMPVA Claim Form, VA Form 

10–7959a. 

c. CHAMPVA Other Health Insurance 

(OHI) Certification, VA Form 10–7959c. 

d. CHAMPVA Potential Liability 

Claim, VA Form 10–7959d. 

e. Claim for Miscellaneous Expenses, 

VA Form 10–7959e. 

OMB Control Number: 2900–0219. 

Type of Review: Revision of a 

currently approved collection. 

Abstracts: 

a. VA Form 10–10d is used to 

determine eligibility of persons 

applying for healthcare benefits under 

the CHAMPVA program. 

b. VA Form 10–7959a is used to 

accurately adjudicate and process 

beneficiaries claims for payment/ 

reimbursement of related healthcare 

expenses. 

c. VA Form 10–7959c is used to 

systematically obtain other health 

insurance information and to correctly 

coordinate benefits among all liable 

parties. 

d. VA Form 10–7959d is used to 

gather additional information relative to 

the injury or illness as well as third 

party claim information. 

e. Beneficiaries complete VA Form 

10–7959e to claim payment/ 

reimbursement of expenses related to 

spina bifida and certain covered birth 

defects. 

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 

March 1, 2010, at pages 9276–9277. 

Affected Public: Individuals or 

households, business or other for-profit, 

and not-for-profit institutions. 

Estimated Annual Burden: 

a. VA Form 10–10d—4,411 hours. 

b. VA Form 10–7959a—37,336 

hours. 

c. VA Form 10–7959c—13,456 

hours. 

d. VA Form 10–7959d—467 hours. 

e. VA Form 10–7959e—725 hours. 

Estimated Average Burden Per 

Respondent: 

a. VA Form 10–10d—10 minutes. 

b. VA Form 10–7959a—10 minutes. 

c. VA Form 10–7959c—10 minutes. 

d. VA Form 10–7959d—7 minutes. 

e. VA Form 10–7959e—10 minutes. 

Frequency of Response: On occasion. 

Estimated Number of Respondents: 

a. VA Form 10–10d—26,468. 

b. VA Form 10–7959a—224,018. 

c. VA Form 10–7959c—80,733. 

d. VA Form 10–7959d—4,000. 

e. VA Form 10–7959e—4,400. 

Dated: May 4, 2010. 

By direction of the Secretary. 

Denise McLamb, 

Program Analyst, Enterprise Records Service. 

[FR Doc. 2010–10796 Filed 5–6–10; 8:45 am] 

BILLING CODE 8320–01–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

[OMB Control No. 2900–0712] 

Agency Information Collection (Nationwide Customer Satisfaction Surveys) 

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, 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 June 7, 2010. 

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– 

0712’’ in any correspondence. 

FOR FURTHER INFORMATION CONTACT: 

Denise McLamb, Enterprise Records 

Service (005R1B), Department of 

Veterans Affairs, 810 Vermont Avenue, 

NW., Washington, DC 20420, (202) 461– 

7485, fax (202) 273–0443 or e-mail 

denise.mclamb@va.gov. Please refer to 

‘‘OMB Control No. 2900–0712.’’ 

SUPPLEMENTARY INFORMATION: 

Title: Nation-wide Customer 

Satisfaction Surveys, VA Forms 1465–2 

through 1465–4. 

OMB Control Number: 2900–0712. 

Type of Review: Revision of a 

currently approved collection. 

Abstract: The Survey of Health 

Experience of Patients (SHEP) Survey is 

used to obtain information from VA 

patients that will be used to identify 

problems or compliant and to improve 

the quality of health care services 

delivered to veterans. Data will be use 

to measure improvement toward the 

goal of matching or exceeding non-VA 

external benchmark performance. 

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 March 

1, 2010, at page 9277. 

Affected Public: Individuals or 

households. 

Estimated Annual Burden: 

a. Inpatient Short Form, VA Form 

10–1465–2—18,750 hours. 

b. Ambulatory Care Long Form, VA 

Form 10–1465–3—9,802 hours. 

c. Ambulatory Care Short Form, VA 

Form 10–1465–4—67,573 hours. 


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