Information Collection

DBQs

IC 195946 under ICR 201101-2900-010 · OMB 2900-0776.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0776 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 21-0960M-8 DBQs Form
VA Form 21-0960A-2 Artery and Vein Conditions (Vascular Diseases Including 21-0960A-2.pdf www.va.gov/vaforms Form
VA Form 21-0960A-3 Hypertension DBQ 21-0960A-3.pdf www.va.gov/vaforms Form
VA Form 21-0960A-4 Non-Ischemic Heart Disease (Including Arrhythmias and Su 21-0960A-4.pdf www.va.gov/vaforms Form
VA Form 21-0960C-4 Diabetic Peripheral Neuropathy (Diabetic Sensory-Motor P 21-0960C-4.pdf www.va.gov/vaforms Form
VA Form 21-0960E-1 Diabetes Mellitus DBQ 21-0960E-1.pdf www.va.gov/vaforms Form
VA Form 21-0960F-1 Scars/Disfigurement DBQ 21-0960F-1.pdf www.va.gov/vaforms Form
VA Form 21-0960F-2 Skin Diseases DBQ 21-0960F-2.pdf www.va.gov/vaforms Form
VA Form 21-0960M-1 Amputations DBQ 21-0960M-1.pdf www.va.gov/vaforms Form
VA Form 21-0960M-2 Ankle Conditions DBQ 21-0960M-2.pdf www.va.gov/vaforms Form
VA Form 21-0960M-4 Elbow and Forearm Conditions DBQ 21-0960M-4.pdf www.va.gov/vaforms Form
VA Form 21-0960M-5 Flatfoot (Pes Planus) DBQ 21-0960M-5.pdf www.va.gov/vaforms Form
VA Form 21-0960M-6 Foot Miscellaneous (Other than Flatfoot/Pes Planus) DBQ 21-0960M-6.pdf www.va.gov/vaforms Form
VA Form 21-0960M-7 Hand and Finger Conditions DBQ 21-0960M-7.pdf www.va.gov/vaforms Form
VA Form 21-0960M-8 Hip and Thigh Conditions DBQ 21-0960M-8.pdf www.va.gov/vaforms Form
VA Form 21-0960M-9 Knee and Lower Leg Conditions DBQ 21-0960M-9.pdf www.va.gov/vaforms Form
VA Form 21-0960M-1 Muscle Injuries DBQ 21-0960M-10.pdf www.va.gov/vaforms Form
VA Form 21-0960M-1 Shoulder and Arm Conditions DBQ 21-0960M-12.pdf www.va.gov/vaforms Form
VA Form 21-0960M-1 Temporomandibular Joint Conditions DBQ 21-0960M-15.pdf www.va.gov/vaforms Form
VA Form 21-0960M-1 Wrist Conditions DBQ 21-0960M-16.pdf www.va.gov/vaforms Form
VA Form 21-0960N-2 Eye Conditions DBQ 21-0960N-2.pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	DBQs	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-0960M-8	Hip and Thigh Conditions DBQ	21-0960M-8.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-9	Knee and Lower Leg Conditions DBQ	21-0960M-9.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-10	Muscle Injuries DBQ	21-0960M-10.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-12	Shoulder and Arm Conditions DBQ	21-0960M-12.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-15	Temporomandibular Joint Conditions DBQ	21-0960M-15.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-16	Wrist Conditions DBQ	21-0960M-16.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960N-2	Eye Conditions DBQ	21-0960N-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960A-2	Artery and Vein Conditions (Vascular Diseases Including Varicose Veins) DBQ	21-0960A-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960A-3	Hypertension DBQ	21-0960A-3.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960A-4	Non-Ischemic Heart Disease (Including Arrhythmias and Surgery) DBQ	21-0960A-4.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-4	Diabetic Peripheral Neuropathy (Diabetic Sensory-Motor Peripheral Neuropathy) DBQ	21-0960C-4.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960E-1	Diabetes Mellitus DBQ	21-0960E-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960F-1	Scars/Disfigurement DBQ	21-0960F-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960F-2	Skin Diseases DBQ	21-0960F-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-1	Amputations DBQ	21-0960M-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-2	Ankle Conditions DBQ	21-0960M-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-4	Elbow and Forearm Conditions DBQ	21-0960M-4.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-5	Flatfoot (Pes Planus) DBQ	21-0960M-5.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-6	Foot Miscellaneous (Other than Flatfoot/Pes Planus) DBQ	21-0960M-6.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-7	Hand and Finger Conditions DBQ	21-0960M-7.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 725,000	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	725,000	725,000
Annual IC Time Burden (Hours)	311,250	311,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.