OMB21-4192(11-9-07)

Supporting Statement for VA Form 21-4192

Request for Employment Information in Connection with Claim for Disability Benefits

(2900-0065)

A. Justification

1. The Department of Veterans Affairs (VA), through its Veterans Benefits Administration (VBA), administers an integrated program of benefits and services established by law for veterans, service personnel, and their dependents and/or beneficiaries. Information is requested by this form under the authority of 38 U.S.C. 1502 and 38 CFR 3.340 through 3.342.

2. VA Form 21-4192 is used to gather necessary employment information from veterans’ employers so VA can determine eligibility to increased disability benefits based on unemployability.

3. VA Form 21-4192 is primarily submitted to employers by VA. However, the form is available on the VBA website for downloading by claimants. Claimants may print and submit the form to VA or their employers non-electronically.

4. Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency which maintains the necessary information, nor is it available from other sources within our Department.

5. The form used to collect the information is brief and can be completed by any employer including small businesses.

6. The VA compensation and pension programs require the actual termination date of the claimant’s employment and reason for termination in order to determine effective dates and entitlement in unemployability cases. These forms solicit such evidence.

7. There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.

8. The Department notice was published in the Federal Register on July 30, 2007, (Volum 73, Number 145, page 41584-41585). No outside consultations were solicited as no major changes are being made to the form. Field stations have not reported any difficulty on the part of respondents in using the VA Form 21-4192. No comments were received.

9. No payments or gifts to respondents have been made under this collection of information.

10. The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22, "Compensation, Pension, Education and Rehabilitation Records - VA" as set forth in Privacy Act Issuances, 1993 compilation found in 42 Fed. Reg. 49726 (9/27//1977).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 60,000 per year.

b. Frequency of Response is one time for most beneficiaries.

c. Annual burden is 15,000 hours.

d. The estimated completion time of 15 minutes is based on review by staff personnel and previous usage of this form.

e. The total estimated cost to respondents is $225,000 (15,000 hours x $15 per hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $3,454,379

(GS-12/5 @ $36.26 x 60,000 x 21/60 minutes = $ 761,460)

(GS- 9/5 @ $25.00 x 60,000 x 93/60 minutes = $2,325,000)

(GS- 3/5 @ $13.14 x 60,000 x 28/60 minutes = $ 367,919)

b. Printing and production cost $1,500

c. Total cost to government $3,455,879

15. There is no change in the reporting burden.

16. The information collection is not for publication or tabulation use.

17. The collection instrument, VA Form 21-4192, may be reproduced and/or stocked by the respondents and veterans service organizations. This VA form does not display an expiration date, and if required to do so would result in unnecessary waste of existing stocks of this form. This form is submitted to OMB every 3 years. As such, this date requirement would also result in an unnecessary burden on the respondents and would delay Department action on the benefit being sought. VA also seeks to minimize its cost to itself of collecting, processing and using the information by not displaying the expiration date. For the reasons stated, VA continues to seek an exemption that waives the displaying of the expiration date on VA Form 21-4192.

18. This submission does not contain any exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

1. The Veterans Benefits Administration does not collect information employing statistical methods.