2900-0704 justification

Supporting Statement for VA Form 21-0819

VA/DOD Joint Disability Evaluaton Board Claim

2900-2900-0704

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. Title 38 U.S.C. 5101(a) provides that a specific claim in the form provided by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by the Secretary. This form is used in a joint effort between VA and the Department of Defense (DOD), as recommended by former President Bush’s Interagency Task Force on Returning Global War on Terror Heroes, to determine an injured or ill Global War on Terrorism (GWOT) service member’s military readiness fitness for military retention, level of disability for retirement,and VA Disability compensation.

2. VA Form 21-0819 is used to gather the necessary information to determine eligibility for active duty service members who may be eligible for a DOD Disability Evaluation Board and VA compensation. Without this information, determination of entitlement would not be possible.

3. VA Form 21-0819 is available on the One-VA web site in a fillable electronic format. VBA maintains a secure server for forms of this type, but does not currently have the technology in place to allow for the complete submission of the form. Validation edits are performed to assure data integrity. Efforts within VA are underway to provide a mechanism to allow the information to be submitted electronically with a recognized signature technology. There currently is no utility process in place that will allow the data submitted on the form to be incorporated with an existing centralized legacy database. This form will not be added to Veterans Online Applications (VONAPP) because of it must be completed by the service member, VA and representatives from DoD.

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 collection of information does not involve small businesses or entities.

6. This form is designed in a “user friendly” format, incorporating plain English, to comply with the President’s Memorandum of June 1, 1998, Plain Language in Government Writing.

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

8. Department notice was published in the Federal Register on October 14, 2009 at pages 52841-52842. There were no comments in response to this notice.

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 “Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28),” published at 74 FR 29275 (June 19, 2009).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 14,000 per year.

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

c. Annual burden is 7,000 hours.

d. The estimated completion time of 30 minutes is based on review by staff personnel.

e. The total estimated cost to respondents is $105,000 (7,000 hours x $15/hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $434,280

(GS-12/5 @ $36.72 x 14,000 x 30 minutes = $257,040)

(GS-9/5 @ $25.32 x 14,000 x 30 minutes = $177,240)

b. Printing and production cost $284

c. Total cost to government $434,564

15. This is no change in the reporting burden.

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

17. The collection instrument, VA Form 21-0819, 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 will be 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. 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 seeks an exemption that waives the displaying of the expiration date on VA Form 21-0819.

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

B. Collection of Information Employing Statistical Methods

The data collection does not employ statistical methods.