Disability Benefits Questionnaires - Group 2

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 21-0960N-2 Eye Conditions DBQ	Form	New	Available
Form VA Form 21-0960M-1 Wrist Conditions DBQ	Form	New	Available
Form VA Form 21-0960M-1 Temporomandibular Joint Conditions DBQ	Form	New	Available
Form VA Form 21-0960M-1 Shoulder and Arm Conditions DBQ	Form	New	Available
Form VA Form 21-0960M-1 Muscle Injuries DBQ	Form	New	Available
Form VA Form 21-0960M-9 Knee and Lower Leg Conditions DBQ	Form	New	Available
Form VA Form 21-0960M-7 Hand and Finger Conditions DBQ	Form	New	Available
Form VA Form 21-0960M-6 Foot Miscellaneous (Other than Flatfoot/Pes Planus) DBQ	Form	New	Available
Form VA Form 21-0960M-5 Flatfoot (Pes Planus) DBQ	Form	New	Available
Form VA Form 21-0960M-4 Elbow and Forearm Conditions DBQ	Form	New	Available
Form VA Form 21-0960M-2 Ankle Conditions DBQ	Form	New	Available
Form VA Form 21-0960M-1 Amputations DBQ	Form	New	Available
Form VA Form 21-0960F-2 Skin Diseases DBQ	Form	New	Available
Form VA Form 21-0960F-1 Scars/Disfigurement DBQ	Form	New	Available
Form VA Form 21-0960E-1 Diabetes Mellitus DBQ	Form	New	Available
Form VA Form 21-0960C-4 Diabetic Peripheral Neuropathy (Diabetic Sensory-Motor Peripheral Neuropathy) DBQ	Form	New	Available
Form VA Form 21-0960A-4 Non-Ischemic Heart Disease (Including Arrhythmias and Surgery) DBQ	Form	New	Available
Form VA Form 21-0960A-3 Hypertension DBQ	Form	New	Available
Form VA Form 21-0960A-2 Artery and Vein Conditions (Vascular Diseases Including Varicose Veins) DBQ	Form	New	Available
Form VA Form 21-0960M-8 Hip and Thigh Conditions DBQ	Form	New	Available
201101-2900-010 Part A (Comp Svc addressing comments 7-6-11) .docx	Supporting Statement A	Uploaded 2011-07-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
195946	DBQs	Form	New	Eye Conditions DBQ
195946	DBQs	Form	New	Wrist Conditions DBQ
195946	DBQs	Form	New	Temporomandibular Joint Conditions DBQ
195946	DBQs	Form	New	Shoulder and Arm Conditions DBQ
195946	DBQs	Form	New	Muscle Injuries DBQ
195946	DBQs	Form	New	Knee and Lower Leg Conditions DBQ
195946	DBQs	Form	New	Hand and Finger Conditions DBQ
195946	DBQs	Form	New	Foot Miscellaneous (Other than Flatfoot/Pes Planus) DBQ
195946	DBQs	Form	New	Flatfoot (Pes Planus) DBQ
195946	DBQs	Form	New	Elbow and Forearm Conditions DBQ
195946	DBQs	Form	New	Ankle Conditions DBQ
195946	DBQs	Form	New	Amputations DBQ
195946	DBQs	Form	New	Skin Diseases DBQ
195946	DBQs	Form	New	Scars/Disfigurement DBQ
195946	DBQs	Form	New	Diabetes Mellitus DBQ
195946	DBQs	Form	New	Diabetic Peripheral Neuropathy (Diabetic Sensory-Motor Peripheral Neuropathy) DBQ
195946	DBQs	Form	New	Non-Ischemic Heart Disease (Including Arrhythmias and Surgery) DBQ
195946	DBQs	Form	New	Hypertension DBQ
195946	DBQs	Form	New	Artery and Vein Conditions (Vascular Diseases Including Varicose Veins) DBQ
195946	DBQs	Form	New	Hip and Thigh Conditions DBQ

ICR Details

OMB Control No: 2900-0776	ICR Reference No: 201101-2900-010
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Disability Benefits Questionnaires - Group 2
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/05/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/09/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	36 Months From Approved
Responses	725,000	0	0
Time Burden (Hours)	311,250	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: These forms are being created to assist veterans who require a disability examination in support of a claim for VA benefits. These forms will be used to record the findings of the examining physician.

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Authorizing Statute(s): US Code: 38 USC 501(a)
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 56	03/23/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 110	06/08/2011
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
DBQs	VA Form 21-0960M-4, VA Form 21-0960M-5, VA Form 21-0960M-7, VA Form 21-0960M-10, VA Form 21-0960M-8, VA Form 21-0960C-4, VA Form 21-0960M-12, VA Form 21-0960M-16, VA Form 21-0960M-15, VA Form 21-0960N-2, VA Form 21-0960E-1, VA Form 21-0960A-2, VA Form 21-0960A-3, VA Form 21-0960M-9, VA Form 21-0960F-1, VA Form 21-0960M-2, VA Form 21-0960F-2, VA Form 21-0960M-1, VA Form 21-0960A-4, VA Form 21-0960M-6	Artery and Vein Conditions (Vascular Diseases Including Varicose Veins) DBQ ,   Hypertension DBQ ,   Non-Ischemic Heart Disease (Including Arrhythmias and Surgery) DBQ ,   Diabetic Peripheral Neuropathy (Diabetic Sensory-Motor Peripheral Neuropathy) DBQ ,   Diabetes Mellitus DBQ ,   Scars/Disfigurement DBQ ,   Skin Diseases DBQ ,   Amputations DBQ ,   Ankle Conditions DBQ ,   Elbow and Forearm Conditions DBQ ,   Flatfoot (Pes Planus) DBQ ,   Foot Miscellaneous (Other than Flatfoot/Pes Planus) DBQ ,   Hand and Finger Conditions DBQ ,   Hip and Thigh Conditions DBQ ,   Knee and Lower Leg Conditions DBQ ,   Muscle Injuries DBQ ,   Shoulder and Arm Conditions DBQ ,   Temporomandibular Joint Conditions DBQ ,   Wrist Conditions DBQ ,   Eye Conditions DBQ

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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	725,000	0	0	725,000	0	0
Annual Time Burden (Hours)	311,250	0	0	311,250	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 request.

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Annual Cost to Federal Government: $724,255,875

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]? No

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: 06/09/2011

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