Disability Benefits Questionnaires - Group 3

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 21-0960C-5 Central Nervous System and Neuromusculo Diseases Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960G-4 Intestinal Surgery (bowel resection, colostomy, iliostomy) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960L-2 Sleep Apnea Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960G-8 Infectious Intestinal Disorders (including bacterial and parasitic infections) Disability Benefits Questionnaire	Form	New	Repair queued
Form VA Form 21-0960G-3 Intestinal Disorders (other than surgical or infectious) (including irritable bowel syndrome, crohn's disease, ulcerative colitis, and diverticulitis) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960N-1 Ear Conditions (including vestibular and infectious) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960M-1 Osteomyelitis Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960M-3 Arthritis Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960K-2 Gynecological Conditions Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960K-1 Breast Conditions and Disorders Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960H-2 Rectum and Anus Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960G-7 Stomach and Duodenal Conditions (not including GERD or esophageal disorders) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960G-6 Peritoneal Adhesions Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960G-5 Hepatitis, Cirrhosis and other Liver Conditions Disability Benefits Questionnaire	Form	New	Repair queued
Form VA Form 21-0960G-2 Gallbladder and Pancreas Conditions Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960G-1 Esophageal Disorders (including GERD) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960C-9 Multiple Sclerosis (MS) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960C-8 Headaches (including migraine headaches) Disability Benefits Questionnaire	Form	New	Available
DBQ Group3_Supplemental_Statement_(07-25-11)11[1].doc	Supplementary Document	Uploaded 2011-07-25	Available
Supporting_Statement_for_VAF_21-0960_Group_3_(07-25-11)[1].docx	Supporting Statement A	Uploaded 2011-07-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Central Nervous System and Neuromusculo Diseases Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Intestinal Surgery (bowel resection, colostomy, iliostomy) Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Sleep Apnea Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Infectious Intestinal Disorders (including bacterial and parasitic infections) Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Intestinal Disorders (other than surgical or infectious) (including irritable bowel syndrome, crohn's disease, ulcerative colitis, and diverticulitis) Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Ear Conditions (including vestibular and infectious) Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Osteomyelitis Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Arthritis Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Gynecological Conditions Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Breast Conditions and Disorders Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Rectum and Anus Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Stomach and Duodenal Conditions (not including GERD or esophageal disorders) Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Peritoneal Adhesions Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Hepatitis, Cirrhosis and other Liver Conditions Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Gallbladder and Pancreas Conditions Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Esophageal Disorders (including GERD) Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Multiple Sclerosis (MS) Disability Benefits Questionnaire
196002	Disability Benefits Questionnaires (Group 3)	Form	New	Headaches (including migraine headaches) Disability Benefits Questionnaire

ICR Details

OMB Control No: 2900-0778	ICR Reference No: 201101-2900-013
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Disability Benefits Questionnaires - Group 3
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 without change	Conclusion Date: 11/06/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/27/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2014	36 Months From Approved
Responses	350,000	0	0
Time Burden (Hours)	102,500	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: These forms are being created to assist veteran's who require a disability examination in support of a claim for VA benefits. 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) Name of Law: Rules and Regulations
  

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 73	04/15/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 118	06/20/2011
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
Disability Benefits Questionnaires (Group 3)	VA Form 21-0960G-7, VA Form 21-0960K-2, VA Form 21-0960K-1, VA Form 21-0960M-3, VA Form 21-0960H-2, VA Form 21-0960N-1, VA Form 21-0960C-8, VA Form 21-0960G-1, VA Form 21-0960G-2, VA Form 21-0960G-6, VA Form 21-0960M-11, VA Form 21-0960C-9, VA Form 21-0960G-5, VA Form 21-0960G-3, VA Form 21-0960L-2, VA Form 21-0960C-5, VA Form 21-0960G-8, VA Form 21-0960G-4	Headaches (including migraine headaches) Disability Benefits Questionnaire ,   Multiple Sclerosis (MS) Disability Benefits Questionnaire ,   Esophageal Disorders (including GERD) Disability Benefits Questionnaire ,   Gallbladder and Pancreas Conditions Disability Benefits Questionnaire ,   Hepatitis, Cirrhosis and other Liver Conditions Disability Benefits Questionnaire ,   Peritoneal Adhesions Disability Benefits Questionnaire ,   Stomach and Duodenal Conditions (not including GERD or esophageal disorders) Disability Benefits Questionnaire ,   Rectum and Anus Disability Benefits Questionnaire ,   Breast Conditions and Disorders Disability Benefits Questionnaire ,   Gynecological Conditions Disability Benefits Questionnaire ,   Arthritis Disability Benefits Questionnaire ,   Osteomyelitis Disability Benefits Questionnaire ,   Ear Conditions (including vestibular and infectious) Disability Benefits Questionnaire ,   Intestinal Disorders (other than surgical or infectious) (including irritable bowel syndrome, crohn's disease, ulcerative colitis, and diverticulitis) Disability Benefits Questionnaire ,   Infectious Intestinal Disorders (including bacterial and parasitic infections) Disability Benefits Questionnaire ,   Sleep Apnea Disability Benefits Questionnaire ,   Intestinal Surgery (bowel resection, colostomy, iliostomy) Disability Benefits Questionnaire ,   Central Nervous System and Neuromusculo Diseases Disability Benefits Questionnaire

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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	350,000	0	0	350,000	0	0
Annual Time Burden (Hours)	102,500	0	0	102,500	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 collection.

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Annual Cost to Federal Government: $310,923,070

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: 07/27/2011

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