Supporting Statement for
VAF 21-0960C-5, Central Nervous System and Neuromusculo Diseases Disability Benefits Questionnaire
VAF 21-0960C-8, Headaches (Including Migraine Headaches) Disability Benefits Questionnaire
VAF 21-0960C-9, Multiple Sclerosis (MS) Disability Benefits Questionnaire
VAF 21-0960G-1, Esophageal Disorders (including GERD) Disability Benefits Questionnaire
VAF 21-0960G -2, Gall Bladder and Pancreas Conditions Disability Benefits Questionnaire
VAF 21-0960G-3, Intestinal Disorders (other than Surgical or Infectious) (including Irritable Bowel Syndrome, Crohn’s Disease, Ulcerative Colitis, and Diverticulitis) Disability Benefits Questionnaire
VAF 21-0960G-4, Intestinal Surgery (including Bowel Resection, Colostomy, Iliostomy) Disability Benefits Questionnaire
VAF 21-0960G-5, Hepatitis, Cirrhosis, and other Liver Conditions Disability Benefits Questionnaire
VAF 21-0960G-6, Peritoneal Adhesions Disability Benefits Questionnaire
VAF 21-0960G-7, Stomach and Duodenal Conditions (Not Including GERD or Esophageal Disorders) Disability Benefits Questionnaire
VAF 21-0960G-8, Infectious Intestinal Disorders (including Bacterial and Parasitic Infections) Disability Benefits Questionnaire
VAF 21-0960H-2, Rectum and Anus Conditions (including Hemorrhoids) Disability Benefits Questionnaire
VAF 21-0960K-1 Breast Conditions and Disorders Disability Benefits Questionnaire
VAF 21-0960K-2 Gynecological Conditions Disability Benefits Questionnaire
VAF 21-0960L-2 Sleep Apnea Disability Benefits Questionnaire
VAF 21-0960M-3, Arthritis Disability Benefits Questionnaire
VAF 21-0960M-11, Osteomyelitis Disability Benefits Questionnaire
VAF 21-0960N-1, Ear Conditions (including Vestibular and Infectious) Disability Benefits Questionnaire
(2900-xxxx)
A. Justification
1. The Department of Veterans Affairs (VA), through its Veterans Benefits Administration (VBA), administers an integrated program of benefits and services established by law for veterans, service personnel, and their dependents and/or beneficiaries. 38 U.S.C. 501 (a), Rules and Regulations, authorizes VA to prescribe all rules and regulations which are necessary or appropriate to carry out the laws administered by the Department, including the methods of making medical examinations. 38 CFR 3.326 authorizes a VA examination where the reasonable probability of a valid claim is indicated in any claim for disability compensation or pension, including claims for benefits set forth under 38 C.F.R. 3.351(d) and (e), benefits based on the need of a veteran, surviving spouse, or parent for regular aid and attendance, and benefits based on a child's incapacity for self-support This provision also stipulates that medical evidence such as hospital reports or any examination reports, from any government or private institution may be accepted for rating a claim without further examination. The VA Form 21-0960 series (disability benefits questionnaires) will be used for disability compensation or pension claims which require an examination and/or receiving private medical evidence that may potentially be sufficient for rating purposes. The disability benefits questionnaires (DBQs) will streamline the process by which a Veteran submits relevant medical evidence to VBA for the purpose of rating disabilities in order to provide timely delivery of benefits to our Nation’s Veterans. The straightforward and standardized questions in the DBQs will improve the quality and timeliness of medical evidence necessary to support a Veteran’s claim for disability benefits, which will enable VA to adjudicate claims faster. The DBQs will, in some circumstances, facilitate a Veteran’s application for disability benefits by engaging a treating physician to aid in administering the C&P examination. Use of the streamlined medical questionnaires by private physicians, at the request of Veterans, as well as by VA contractors and VHA physicians, will create an aggregate timeliness advantage for claims processing and thus help alleviate the claims backlog. Leveraging resources of the private medical community will also enable VHA to redirect physician efforts to care and treatment.
2. The VA Form 21-0960 series will be used to gather necessary information from a claimant’s treating physician regarding the results of medical examinations. VA will gather medical information related to the claimant that is necessary to adjudicate the claim for VA disability benefits. The Disability Benefit Questionnaire title will include the name of the specific disability for which it will gather information. VAF 21-0960C-5, Central Nervous System and Neuromusculo Diseases Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a central nervous system disease; VAF 21-0960C-8, Headaches (including Migraine Headaches) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of headaches; VAF 21-0960C-9, Multiple Sclerosis (MS) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of multiple sclerosis; VAF 21-0960G-1, Esophageal Disorders (including GERD) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any esophageal disorders; VAF 21-0960G-2, Gall Bladder and Pancreas Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any gall bladder and pancreas condition; VAF 21-0960G-3, Intestinal Disorders(Other than Surgical or Infectious (including Irritable Bowel Syndrome, Crohn’s Disease, Ulcerative Colitis, and Diverticulitis) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any intestinal conditions unrelated to surgery or infection; VAF 21-0960G-4, Intestinal Surgery (including Bowel Resection, Colostomy, Iliostomy) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any surgical intestinal condition; VAF 21-0960G-5, Hepatitis, Cirrhosis and other Liver Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any liver condition; VAF 21-0960G-6, Peritoneal Adhesions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of peritoneal adhesions; VAF 21-0960G-7, Stomach and Duodenal Conditions (not including GERD or Esophageal Disorders) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any stomach or duodenum conditions; VAF 21-0960G-8, Infectious Intestinal Disorders (including Bacterial and Parasitic Infections) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any infectious intestinal condition; VAF 21-0960H-2, Rectum and Anus Conditions (including Hemorrhoids) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any rectum or anus condition, which includes hemorrhoids; VAF 21-0960K-1 Breast Conditions and DisordersDisability Benefits Questionnaire will gather information related to the claimant’s diagnosis of a breast condition or disorder; VAF 21-0960K-2 Gynecological Conditions Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of a gynecological condition; VAF 21-0960L-2, Sleep Apnea Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of sleep apnea; VAF 21-0960M-3, Arthritis Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of arthritis; VAF 21-0960M-11, Osteomyelitis Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of osteomyelitis; VAF 21-0960N-1, Ear Conditions (including Vestibular and Infectious) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of an ear disease.
3. Currently the collection of information does not involve the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology. Veterans Online Applications (VONAPP) allows applicants to view, print, and submit applications electronically to VBA; however, the Department is not planning to add VA Form 21-0960 series to VONAPP as it is completed by the examining physician rather than by applicants. For this reason VA is developing a web portal for the public to use as a pathway for private physicians in order to complete and submit forms in the VA Form 21-0960 series (DBQs).
4. Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency which maintains the necessary information, nor is it available from other sources within our Department. Once a claim is received, VA has a duty to assist the Veteran in obtaining all necessary evidence to substantiate their claim. Based upon this duty, VA requests all pertinent medical evidence from the Veteran, any Federal Agencies that may have this evidence, any agency or entity which the Veteran has indicated may have this evidence and from which the Veteran has authorized VA to request the information, as well as VA medical evidence. Once evidence has been found to establish an in-service injury or disease, VA will evaluate to determine if there is sufficient current medical evidence to link a current diagnosis to the service-related injury or disease and rate the disability according to current symptomatology by using the rating schedule criteria in 38 CFR Part 4. For internal VA purposes, the DBQs will replace the current VA examination process in order to obtain the essential medical evidence needed to rate the claim. The forms being used publicly will also benefit both the Veteran and VA by providing the necessary relevant medical evidence without the need to request and obtain a VA examination, thus expediting the process for a swift decision. While the potential for duplication of evidence has long existed to some extent with any evidence received, DBQs do not add any new areas of potential duplication; if a DBQ is received then a VA examination will not be required.
5. The collection of information does not involve small businesses or entities. However, in an effort to assist the entities of the physicians who are required to complete these questionnaires, VA will maintain a web portal internet website. This site will provide private physicians with a paperless way to fill out and submit pertinent medical evidence.
6. The VA compensation and pension programs require current information to determine initial and continuing eligibility for benefits. This form solicits the information needed to determine the level of disability. Without this information, benefits could not be administered effectively. The provisions of 38 CFR § 3.159 state that in a claim for disability compensation, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record, if VA determines it is necessary to decide the claim. A medical examination or opinion is necessary if there is evidence that the Veteran suffered an event, injury or disease in service, or has a disease or symptoms of a disease listed in §§ 3.309, 3.313, 3.316, and 3.317, which manifested during an applicable presumptive period, provided the Veteran has the required service or triggering event to qualify for that presumption, and the information and evidence of record does not contain sufficient competent medical evidence to decide the claim. If the Veteran chooses to have his or her private physician complete a DBQ in lieu of a VA examination, the DBQ will solicit the information needed, per rating schedule criteria, to determine the level of disability without the need to schedule a VA medical examination.
7. There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.
8. The Department notice was published in the Federal Register on April 15, 2011, pages 21429-21430. No comments were received.
9. No payments or gifts to respondents have been made under this collection of information.
10. The records are maintained in the appropriate Privacy Act System of Records identified as ‘‘Compensation, Pension, Education, and Rehabilitation Records—VA (58VA21/22/28)’’as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009).
11. There are no questions of a sensitive nature.
12. Estimate of Information Collection Burden.
a. Number of Respondents is estimated at 350,000 per year for all forms:
VAF 21-0960C-5 – 10,000
VAF 21-0960C-8 – 15,000
VAF 21-0960C-9 – 10,000
VAF 21-0960G-1 – 40,000
VAF 21-0960G -2 – 5,000
VAF 21-0960G-3 – 5,000
VAF 21-0960G-4 – 5,000
VAF 21-0960G-5 – 10,000
VAF 21-0960G-6– 5,000
VAF 21-0960G-7– 10,000
VAF 21-0960G-8 – 5,000
VAF 21-0960H-2 – 10,000
VAF 21-0960K-1 – 30,000
VAF 21-0960K-2 – 20,000
VAF 21-0960L-2 – 5,000
VAF 21-0960M-3 – 100,000
VAF 21-0960M-11 – 40,000
VAF 21-0960N-1 – 25,000
b. Frequency of Response is on occasion for most beneficiaries.
c. Annual burden hour is 102,500:
VAF 21-0960C-5 – 5,000
VAF 21-0960C-8 – 3,750
VAF 21-0960C-9 – 7,500
VAF 21-0960G-1 – 10,000
VAF 21-0960G -2 – 1,250
VAF 21-0960G-3 – 1,250
VAF 21-0960G-4 – 1,250
VAF 21-0960G-5 – 5,000
VAF 21-0960G-6 – 1,250
VAF 21-0960G-7 – 2,500
VAF 21-0960G-8 – 1,250
VAF 21-0960H-2 – 2,500
VAF 21-0960K-1 – 7,500
VAF 21-0960K-2 – 10,000
VAF 21-0960L-2 – 1,250
VAF 21-0960M-3 – 25,000
VAF 21-0960M-11 – 10,000
VAF 21-0960N-1 – 6,250
d. The estimated completion time for each form is as follows:
VAF 21-0960C-5 – 30 minutes
VAF 21-0960C-8 – 15 minutes
VAF 21-0960C-9 – 45 minutes
VAF 21-0960G-1 – 15 minutes
VAF 21-0960G -2 – 15 minutes
VAF 21-0960G-3 – 15 minutes
VAF 21-0960G-4 – 15 minutes
VAF 21-0960G-5 – 30 minutes
VAF 21-0960G-6 – 15 minutes
VAF 21-0960G-7 – 15 minutes
VAF 21-0960G-8 – 15 mintues
VAF 21-0960H-2 – 15 minutes
VAF 21-0960K-1 – 15 minutes
VAF 21-0960K-2 – 30 minutes
VAF 21-0960L-2 – 15 minutes
VAF 21-0960M-3 – 15 minutes
VAF 21-0960M-11 – 15 minutes
VAF 21-0960N-1 – 15 minutes
e. The total estimated cost to respondents is $1,537,500 (102,500 hours x $15 per hour).
13. This submission does not involve any recordkeeping costs.
14. Estimated Costs to the Federal Government: $11,704,960
a. Processing/Analyzing costs
VAF 21-0960C-5
(GS-13/5 @ $48.35 x 10,000 x 30/60 minutes = $241,750)
(GS-12/5 @ $40.66 x 10,000 x 30/60 minutes = $203,300)
(GS-9/5 @ $28.04 x 10,000 x 30/60 minutes = $140,200)
Total: $585,250.00
VAF 21-0960C-8
(GS-13/5 @ $48.35 x 15,000 x 15/60 minutes = $181,312.50)
(GS-12/5 @ $40.66 x 15,000 x 15/60 minutes = $152,475.00)
(GS-9/5 @ $28.04 x 15,000 x 15/60 minutes = $105,150.00)
Total: $438,937.50
VAF 21-0960C-9
(GS-13/5 @ $48.35 x 10,000 x 45/60 minutes = $362,625.00)
(GS-12/5 @ $40.66 x 10,000 x 45/60 minutes = $304,950.00)
(GS-9/5 @ $28.04 x 10,000 x 45/60 minutes = $210,300.00)
Total: $877,875.00
VAF 21-0960G-1
(GS-13/5 @ $48.35 x 40,000 x 15/60 minutes = $483,500.00)
(GS-12/5 @ $40.66 x 40,000 x 15/60 minutes = $406,600.00)
(GS-9/5 @ $28.04 x 40,000 x 15/60 minutes = $280,400.00)
Total: $1,170,500.00
VAF 21-0960G-2
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960G-3
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960G-4
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960G-5
(GS-13/5 @ $48.35 x 10,000 x 30/60 minutes = $241,750)
(GS-12/5 @ $40.66 x 10,000 x 30/60 minutes = $203,300)
(GS-9/5 @ $28.04 x 10,000 x 30/60 minutes = $140,200)
Total: $585,250.00
VAF 21-0960G-6
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960G-7
(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875)
(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650)
(GS-9/5 @ $28.04 x 10,000 x 15/60 minutes = $70,100)
Total: $292,625.00
VAF 21-0960G-8
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960H-2
(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875)
(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650)
(GS-9/5 @ $28.04 x 10,000 x 15/60 minutes = $70,100)
Total: $292,625.00
VAF 21-0960K-1
(GS-13/5 @ $48.35 x 30,000 x 15/60 minutes = $362,625)
(GS-12/5 @ $40.66 x 30,000 x 15/60 minutes = $304,950)
(GS-9/5 @ $28.04 x 30,000 x 15/60 minutes = $210,300)
Total: $877,855.00
VAF 21-0960K-2
(GS-13/5 @ $48.35 x 20,000 x 30/60 minutes = $483,500)
(GS-12/5 @ $40.66 x 20,000 x 30/60 minutes = $406,600)
(GS-9/5 @ $28.04 x 20,000 x 30/60 minutes = $280,400)
Total: $1,170,500.00
VAF 21-0960L-2
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960M-3
(GS-13/5 @ $48.35 x 100,000 x 15/60 minutes = $1,208,750)
(GS-12/5 @ $40.66 x 100,000 x 15/60 minutes = $1,016,500)
(GS-9/5 @ $28.04 x 100,000 x 15/60 minutes = $701,000)
Total: $2,926,250.00
VAF 21-0960M-11
(GS-13/5 @ $48.35 x 40,000 x 15/60 minutes = $483,500)
(GS-12/5 @ $40.66 x 40,000 x 15/60 minutes = $406,600)
(GS-9/5 @ $28.04 x 40,000 x 15/60 minutes = $280,400)
Total: $877,855
VAF 21-0960N-1
(GS-13/5 @ $48.35 x 25,000 x 15/60 minutes = $302,187.50)
(GS-12/5 @ $40.66 x 25,000 x 15/60 minutes = $254,125)
(GS-9/5 @ $28.04 x 25,000 x 15/60 minutes = $175,250)
Total: $731,562.50
b. Printing and production cost $9,000
c. Total cost to government $11,713,960
15. This is a new information collection.
16. The information collection is not for publication or tabulation use.
17. The collection instrument, VA Form 21-0960 series may be reproduced and/or stocked by the respondents and veterans service organizations. These VA forms do not display an expiration date, and if required to do so would result in unnecessary waste of existing stocks of the forms. These forms are submitted to OMB every 3 years. As such, this date requirement would also result in an unnecessary burden on the respondents and would delay Department action on the benefit being sought. VA also seeks to minimize its cost to itself of collecting, processing and using the information by not displaying the expiration date. For the reasons stated, VA continues to seek an exemption that waives the displaying of the expiration date on VA Form 21-0960 series.
18. This submission does not contain any exceptions to the certification statement.
B. Collection of Information Employing Statistical Methods
The data collection does not employ statistical methods.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SF 83 SS VAF 21-8926 |
| Author | Veterans Benefits Administrat |
| File Modified | 0000-00-00 |
| File Created | 2021-02-01 |