Information Collection

Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident

IC 28285 under ICR 201107-2900-021 · OMB 2900-0104.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0104 can be found here:

Documents and Forms

Document Name Document Type
Form 21-4176 Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident Form
21-4176 Report of Accidental Injury in Support of Claim for Comp 21-4176.pdf www.va.gov/vaforms/ Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident	Agency IC Tracking Number:	2900-0104

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.301

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-4176	Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident	21-4176.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,408	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	4,408	4,408
Annual IC Time Burden (Hours)	2,204	2,204
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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