Authorization to Disclose Personal Information to a Third Party (VA Form 21-0845)

Forms and Documents

Document Name	Status
Form VA Form 21-0845 Authorization to Disclose Personal Information to a Third Party Form	Modified
2018-07140.pdf Supporting Statement A	2019-09-12
2019-16023.pdf Supplementary Document	2019-08-06
2019-09248.pdf Supplementary Document	2019-05-14

IC Document Collections

IC ID	Document Title	Status
188786	Authorization to Disclose Personal Information to a Third Party Form	Modified

ICR Details

OMB Control No: 2900-0736	ICR Reference No: 201903-2900-015
Status: Active	Previous ICR Reference No: 201602-2900-037
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Authorization to Disclose Personal Information to a Third Party (VA Form 21-0845)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/24/2020
	Date Received in OIRA: 09/12/2019
Terms of Clearance: In its next revision or extension request of this collection, VA shall: 1. Allow the respondent to request information to be shared with an organization (rather than a specific representative of an organization), or provide a legal opinion from VA OGC that such a change would be inconsistent with regulation or statute and 2. That the mailing address of the respondent is an option field.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2022	36 Months From Approved	04/30/2020
Responses	20,000	0	20,000
Time Burden (Hours)	1,667	0	1,667
Cost Burden (Dollars)	0	0	0

---

Abstract: VA Form 21-0845 is used to release information in the following circumstances: where the individual identifies the particular information and consents to its use; for the purpose for which it was collected or a consistent purpose (i.e., a purpose which the individual might have reasonably expected).

---

Authorizing Statute(s): US Code: 38 USC 5701 Name of Law: Confidential nature of claims
   US Code: 5 USC 552a Name of Law: Privacy Act Law
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 9248	05/07/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 16023	07/29/2019
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Authorization to Disclose Personal Information to a Third Party	VA Form 21-0845	Authorization to Disclose Personal Information to a Third Party

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	20,000	20,000	0	0	0	0
Annual Time Burden (Hours)	1,667	1,667	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $256,788

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/12/2019

---