Disability Benefits Questionnaires Group 4

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 21-0960N-4 Sinusitis/Rhinitis and Other Diseases of the Nose, Throat, Larynx, Pharynx Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960Q-1 Chronic Fatigue Syndrome Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960N-3 Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960L-1 Respiratory Conditions (Other Than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960J-4 Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960I-5 Nutritional Deficiencies Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960I-4 Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960I-3 Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960I-2 HIV - Related Illnesses Disability Benefits Questionnaire	Form	New	Repair queued
Form VA Form 21-0960H-1 Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960E-3 Thyroid and Parathyroid Conditions Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960E-2 Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960D-1 Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960C-1 Seizure Disorders (Epilepsy) Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960C-7 Fibromyalgia Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960C-6 Narcolepsy Disability Benefits Questionnaire	Form	New	Available
Form VA Form 21-0960C-3 Cranial Nerve Conditions Disability Benefits Questionnaire	Form	New	Repair queued
DBQ4 justification.docx	Supporting Statement A	Uploaded 2012-01-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
196008	Disability Benefits Questionnaires Group 4	Form	New	Sinusitis/Rhinitis and Other Diseases of the Nose, Throat, Larynx, Pharynx Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Chronic Fatigue Syndrome Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Respiratory Conditions (Other Than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Nutritional Deficiencies Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	HIV - Related Illnesses Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Thyroid and Parathyroid Conditions Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Seizure Disorders (Epilepsy) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Fibromyalgia Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Narcolepsy Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires Group 4	Form	New	Cranial Nerve Conditions Disability Benefits Questionnaire

ICR Details

OMB Control No: 2900-0781	ICR Reference No: 201101-2900-014
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Disability Benefits Questionnaires Group 4
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: 03/09/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/09/2012
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved. The agency must report this as a violation in the ICB and, in the future, should properly enter such collections as "in use without OMB number".

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2015	36 Months From Approved
Responses	160,000	0	0
Time Burden (Hours)	56,250	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 144	07/27/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 191	10/03/2011
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 4	VA Form 21-0960C-3, VA Form 21-0960H-1, VA Form 21-0960C-7, VA Form 21-0960Q-1, VA Form 21-0960C-6, VA Form 21-0960E-2, VA Form 21-0960L-1, VA Form 21-0960J-4, VA Form 21-0960I-4, VA Form 21-0960I-5, VA Form 21-0960I-3, VA Form 21-0960I-2, VA Form 21-0960N-3, VA Form 21-0960C-11, VA Form 21-0960E-3, VA Form 21-0960N-4, VA Form 21-0960D-1	Cranial Nerve Conditions Disability Benefits Questionnaire ,   Narcolepsy Disability Benefits Questionnaire ,   Fibromyalgia Disability Benefits Questionnaire ,   Seizure Disorders (Epilepsy) Disability Benefits Questionnaire ,   Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire ,   Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire ,   Thyroid and Parathyroid Conditions Disability Benefits Questionnaire ,   Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire ,   HIV - Related Illnesses Disability Benefits Questionnaire ,   Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire ,   Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire ,   Nutritional Deficiencies Disability Benefits Questionnaire ,   Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire ,   Respiratory Conditions (Other Than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire ,   Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire ,   Chronic Fatigue Syndrome Disability Benefits Questionnaire ,   Sinusitis/Rhinitis and Other Diseases of the Nose, Throat, Larynx, Pharynx 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	160,000	0	0	160,000	0	0
Annual Time Burden (Hours)	56,250	0	0	56,250	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 collection.

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Annual Cost to Federal Government: $6,016,924

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: 01/09/2012

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