Disability Benefits Questionnaires

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 21-0960c Parkinson's Disease Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960b Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960a Ischemic Heart Disease (IHD) Disability Benefits Questionnaire	Form	New	Available
21-0960a-c.pdf	Supplementary Document	Uploaded 2010-06-15	Available
VA Form 21-0960 series justification.doc	Supporting Statement A	Uploaded 2010-07-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
193056	Disability Benefits Questionnaires	Form	New	Parkinson's Disease Disability Benefits Questionnaire
193056	Disability Benefits Questionnaires	Form	New	Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire
193056	Disability Benefits Questionnaires	Form	New	Ischemic Heart Disease (IHD) Disability Benefits Questionnaire

ICR Details

OMB Control No: 2900-0749	ICR Reference No: 201005-2900-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Disability Benefits Questionnaires
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 07/15/2010
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/16/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/15/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2011	6 Months From Approved
Responses	62,000	0	0
Time Burden (Hours)	15,500	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 21-0960 series will be used to gather necessary information from a claimant regarding the results of medical examinations.

Emergency Justfication: The Veterans Benefits Administration is requesting emergency approval of the proposed Disability Benefits Questionnaires (VA Form 21-0960 series). 2900-AN54 is the regulation creating presumptive service connection for certain diseases. These questionnaires will streamline the process for determining eligibility for benefits due to these diseases by allowing either VA or private physicians to conduct the medical examination and complete the forms.

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Authorizing Statute(s): US Code: 38 USC 501a Name of Law: Veterans Benefits
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Disability Benefits Questionnaires	VA Form 21-0960b, VA Form 21-0960c, VA Form 21-0960a	Ischemic Heart Disease (IHD) Disability Benefits Questionnaire ,   Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire ,   Parkinson's Disease Disability Benefits Questionnaire

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ICR Summary of Burden

table that charts list of burden

	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	62,000	0	0	62,000	0	0
Annual Time Burden (Hours)	15,500	0	0	15,500	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $4,463,390

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 06/15/2010

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