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Federal forms, ICRs, and supporting documents

Information Collection

Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident

IC 28285 under ICR 200805-2900-008 · OMB 2900-0104.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 21-4176
Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident		 Form
21-4176 Report of Accidental Injury in Support of Claim for Comp
21-4176.pdf
www.va.gov/vaforms/ 		Form

Information Collection (IC) Details

View Information Collection (IC)

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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 21-4176 Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident 21-4176.pdf http://www.va.gov/vaforms/ Yes No Fillable Printable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 4,408 0 0 0 0 4,408
Annual IC Time Burden (Hours) 2,204 0 0 0 0 2,204
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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