STATEMENT OF WITNESS TO ACCIDENT

ICR 199008-2900-019

OMB: 2900-0105

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
147074 Migrated
ICR Details
2900-0105 199008-2900-019
Historical Active 198904-2900-032
VA
STATEMENT OF WITNESS TO ACCIDENT
Extension without change of a currently approved collection   No
Regular
Approved without change 11/21/1990
Retrieve Notice of Action (NOA) 08/31/1990
  Inventory as of this Action Requested Previously Approved
11/30/1993 11/30/1993 11/30/1990
13,200 0 13,200
4,400 0 4,400
0 0 0

VA FORM LETTER 21-806 IS USED TO GATHER NECESSARY INFORMATION FROM A WITNESS TO DETERMINE IF THE VETERAN'S ACCIDENTAL INJURY WAS THE RESULT OF HIS/HER MISCONDUCT.

None
None


No

1
IC Title Form No. Form Name
STATEMENT OF WITNESS TO ACCIDENT FL21-806

  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 13,200 13,200 0 0 0 0
Annual Time Burden (Hours) 4,400 4,400 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/31/1990


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