Disability Benefits Questionnaires

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0749 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 21-0960a Disability Benefits Questionnaires Form
VA Form 21-0960a Ischemic Heart Disease (IHD) Disability Benefits Questio 21-0960a.pdf www.va.gov/vaforms Form
VA Form 21-0960b Hairy Cell and Other B-Cell Leukemias Disability Benefit 21-0960b.pdf www.va.gov/vaforms Form
VA Form 21-0960c Parkinson's Disease Disability Benefits Questionnaire 21-0960c.pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Disability Benefits Questionnaires	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.351e 38 CFR 3.326 38 CFR 3.351d

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-0960a	Ischemic Heart Disease (IHD) Disability Benefits Questionnaire	21-0960a.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960b	Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire	21-0960b.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960c	Parkinson's Disease Disability Benefits Questionnaire	21-0960c.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title: Compensation, Pension, Education, and Rehabilitation RecordsVA (58VA21/22/28)	FR Citation: 74 FR 117

Number of Respondents: 62,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	62,000	62,000
Annual IC Time Burden (Hours)	15,500	15,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.