Supporting Statement for
VAF 21-0960a, Ischemic Heart Disease (IHD) Disability Benefits Questionnaire
VAF 21-0960b, Hairy Cell and Other B-cell Leukemias Disability Benefits Questionnaire
VAF 21-0960c, Parkinson's Disease Disability Benefits Questionnaire
(2900-xxxx)
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. 38 U.S.C. 501 (a) authorizes VA to prescribe all rules and regulations which are necessary or appropriate to carry out the laws administered by the Department, including the methods of making medical examinations. 38 CFR 3.326 authorizes a VA examination where the reasonable probability of a valid claim is indicated in any claim for disability compensation or pension, including claims for benefits set forth under 38 C.F.R. 3.351(d) and (e), benefits based on the need of a veteran, surviving spouse, or parent for regular aid and attendance, and benefits based on a child's incapacity for self-support. VA Form 21-0960 series will be used for disability compensation or pension claims which require an examination.
2. The VA Form 21-0960 series will be used to gather necessary information from a claimant’s treating physician regarding the results of medical examinations. VA will gather medical information related to the claimant that is necessary to adjudicate the claim for VA disability benenfits. The Disability Benefit Questionnaire title will include the name of the specific disability for which it will gather information. Form 21-0960a, Ischemic Heart Disease (IHD) Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of ischemic heart disease. Form 21-0960b, Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of Leukemia. Form 21-0960c, Parkinsons Disease Disability Benefits Questionnaire will gather specific information related to the claimant’s diagnosis of Parkinsons Disease.
3. The collection of information does not involve the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology. Veterans Online Applications (VONAPP) allows applicants to view, print and submit applications electronically to VBA; however, the Department is not planning to add VA Form 21-0960 series to VONAPP as it is completed by the examining physican.
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. The VA compensation and pension programs require current information to determine initial and continuing eligibility for benefits. This form solicits the information needed to determine the level of disability. Without this information, benefits could not be administered effectively.
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 June 15, 2010, pages 33897-33898. 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 ‘‘Compensation, Pension, Education, and Rehabilitation Records—VA (58VA21/22/28)’’as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (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:
Ischemic Heart Disease (IHD) Disability Benefits Questionnaire, VA Form 21-0960A – 55,000.
Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire, VA Form 21-0960B – 2,000.
Parkinson’s Disease Disability Benefits Questionnaire, VA Form 21-0960C – 5,000.
b. Frequency of Response is on occasion for most beneficiaries.
c. Annual burden:
Ischemic Heart Disease (IHD) Disability Benefits Questionnaire, VA Form 21-0960A – 13,750.
Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire, VA Form 21-0960B – 500.
Parkinson’s Disease Disability Benefits Questionnaire, VA Form 21-0960C – 1,250.
.d. The estimated completion time is15 minutes for each form.
e. The total estimated cost to respondents is $232,500 (15,500 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 $4,454,390
(GS-13/5 @ $48.35 x 62,000 x 30/60 minutes = $1,498,850)
(GS-12/5 @ $40.66 x 62,000 x 60/60 minutes = $2,520,920)
(GS-9/5 @ $28.04 x 62,000 x 15/60 minutes = $434,620)
b. Printing and production cost $9,000
c. Total cost to government $4,463,390
15. This is a new information collection.
16. The information collection is not for publication or tabulation use.
17. The collection instrument, VA Form 21-0960 series may be reproduced and/or stocked by the respondents and veterans service organizations. Thes VA forms do not display an expiration date, and if required to do so would result in unnecessary waste of existing stocks of the forms. These 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 21-0960 series.
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.
| File Type | application/msword |
| File Title | SF 83 SS VAF 21-8926 |
| Author | Veterans Benefits Administrat |
| File Modified | 2010-07-02 |
| File Created | 2010-06-15 |