Information Collection

Disability Benefits Questionnaires

IC 193056 under ICR 201005-2900-009 · OMB 2900-0749.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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: ÂCompensation, Pension, Education, and Rehabilitation RecordsÂVA (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 %

table that charts list of burden
	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

table that charts IC Documents
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.