Information Collection

Request for Employment Information in Connection with Claim for Disability Benefits

IC 28204 under ICR 200707-2900-015 · OMB 2900-0065.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0065 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits	Form
21-4192 Request for Employment Information in Connection with Cl 21-4192.pdf www.va.gov/vaforms/	Form

IC Title:

Request for Employment Information in Connection with Claim for Disability Benefits

Agency IC Tracking Number:

2900-0065

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 3.341 38 CFR 3.342 38 CFR 3.340

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-4192	Request for Employment Information in Connection with Claim for Disability Benefits	21-4192.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	60,000	60,000
Annual IC Time Burden (Hours)	15,000	15,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.