Information Collection

Disability Benefits Questionnaires Group 4

IC 196008 under ICR 201101-2900-014 · OMB 2900-0781.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0781 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-0960C-3 Disability Benefits Questionnaires Group 4	Form
VA Form 21-0960C-3 Cranial Nerve Conditions Disability Benefits Questionnai 21-0960C-3.pdf www.va.gov/vaforms	Form
VA Form 21-0960C-6 Narcolepsy Disability Benefits Questionnaire 21-0960C-6.pdf www.va.gov/vaforms	Form
VA Form 21-0960C-7 Fibromyalgia Disability Benefits Questionnaire 21-0960C-7.pdf www.va.gov/vaforms	Form
VA Form 21-0960C-1 Seizure Disorders (Epilepsy) Disability Benefits Questio 21-0960C-11.pdf www.va.gov/vaforms	Form
VA Form 21-0960D-1 Oral and Dental Conditions Including Mouth, Lips and Ton 21-0960D-1.pdf www.va.gov/vaforms	Form
VA Form 21-0960E-2 Endocrine Diseases (Other than Thyroid, Parathyroid or D 21-0960E-2.pdf www.va.gov/vaforms	Form
VA Form 21-0960E-3 Thyroid and Parathyroid Conditions Disability Benefits Q 21-0960E-3.pdf www.va.gov/vaforms	Form
VA Form 21-0960H-1 Hernias (Including Abdominal, Inguinal, and Femoral Hern 21-0960H-1.pdf www.va.gov/vaforms	Form
VA Form 21-0960I-2 HIV - Related Illnesses Disability Benefits Questionnair 21-0960I-2.pdf www.va.gov/vaforms	Form
VA Form 21-0960I-3 Infectious Diseases (Other than HIV-Related Illness, Chr 21-0960I-3.pdf www.va.gov/vaforms	Form
VA Form 21-0960I-4 Systemic Lupus Erythematosus (SLE) and Other Autoimmune 21-0960I-4.pdf www.va.gov/vaforms	Form
VA Form 21-0960I-5 Nutritional Deficiencies Disability Benefits Questionnai 21-0960I-5.pdf www.va.gov/vaforms	Form
VA Form 21-0960J-4 Urinary Tract (Including Bladder and Urethra) Conditions 21-0960J-4.pdf www.va.gov/vaforms	Form
VA Form 21-0960L-1 Respiratory Conditions (Other Than Tuberculosis and Slee 21-0960L-1.pdf www.va.gov/vaforms	Form
VA Form 21-0960N-3 Loss of Sense of Smell and/or Taste Disability Benefits 21-0960N-3.pdf www.va.gov/vaforms	Form
VA Form 21-0960Q-1 Chronic Fatigue Syndrome Disability Benefits Questionnai 21-0960Q-1.pdf www.va.gov/vaforms	Form
VA Form 21-0960N-4 Sinusitis/Rhinitis and Other Diseases of the Nose, Throa 21-0960N-4.pdf www.va.gov/vaforms	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Disability Benefits Questionnaires Group 4

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-0960C-3	Cranial Nerve Conditions Disability Benefits Questionnaire	21-0960C-3.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-6	Narcolepsy Disability Benefits Questionnaire	21-0960C-6.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-7	Fibromyalgia Disability Benefits Questionnaire	21-0960C-7.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-11	Seizure Disorders (Epilepsy) Disability Benefits Questionnaire	21-0960C-11.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960D-1	Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire	21-0960D-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960E-2	Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire	21-0960E-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960E-3	Thyroid and Parathyroid Conditions Disability Benefits Questionnaire	21-0960E-3.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960H-1	Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire	21-0960H-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-2	HIV - Related Illnesses Disability Benefits Questionnaire	21-0960I-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-3	Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire	21-0960I-3.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-4	Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire	21-0960I-4.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-5	Nutritional Deficiencies Disability Benefits Questionnaire	21-0960I-5.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960J-4	Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire	21-0960J-4.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960L-1	Respiratory Conditions (Other Than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire	21-0960L-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960N-3	Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire	21-0960N-3.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960Q-1	Chronic Fatigue Syndrome Disability Benefits Questionnaire	21-0960Q-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960N-4	Sinusitis/Rhinitis and Other Diseases of the Nose, Throat, Larynx, Pharynx Disability Benefits Questionnaire	21-0960N-4.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: 160,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	160,000	160,000
Annual IC Time Burden (Hours)	56,250	56,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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