Supporting Statement for
VAF 21-0960A-2, Artery and Vein Conditions (vascular diseases including varicose veins) Disability Benefits Questionnaire
VAF 21-0960A-3, Hypertension Disability Benefits Questionnaire
VAF 21-0960A-4, Heart Disease (including IHD, Non-IHD, Arrhythmias and Surgery) Disability Benefits Questionnaire
VAF 21-0960C-4, Diabetic Peripheral Neuropathy (diabetic sensory-motor peripheral neuropathy) Disability Benefits Questionnaire
VAF 21-0960E-1, Diabetes Mellitus Disability Benefits Questionnaire
VAF 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire
VAF 21-0960F-2 Skin Diseases Disability Benefits Questionnaire
VAF 21-0960M-1 Amputations Disability Benefits Questionnaire
VAF 21-0960M-2 Ankle Conditions Disability Benefits Questionnaire
VAF 21-0960M-4 Elbow and Forearm Conditions Disability Benefits Questionnaire
VAF 21-0960M-5 Flatfoot (pes planus) Disability Benefits Questionnaire
VAF 21-0960M-6 Foot Miscellaneous (other than flatfoot (pes planus)) Disability Benefits Questionnaire
VAF 21-0960M-7 Hand and Finger Conditions Disability Benefits Questionnaire
VAF 21-0960M-8 Hip and Thigh Conditions Disability Benefits Questionnaire
VAF 21-0960M-9 Knee and Lower Leg Conditions Disability Benefits Questionnaire
VAF 21-0960M-10 Muscle Injuries Disability Benefits Questionnaire
VAF 21-0960M-12 Shoulder and Arm Conditions Disability Benefits Questionnaire
VAF 21-0960M-15 Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire
VAF 21-0960M-16 Wrist Conditions Disability Benefits Questionnaire
VAF 21-0960N-2 Eye Conditions 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) 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 21-0960A-2, Artery and Vein Conditions vascular diseases including varicose veins) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of arteries, veins, and/or peripheral vascular disease; VAF 21-0960A-3, Hypertension, Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of hypertension; VAF 21-0960A-4, Heart Disease (including IHD, Non-IHD, Arrhythmias and Surgery) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any non-ischemic heart disease; VAF 21-0960C-4, Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of a diabetic sensory-motor peripheral neuropathy condition; VAF 21-0960E-1, Diabetes Mellitus Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of diabetes mellitus; VAF 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of any scars or disfigurement; VAF 21-0960F-2, Skin Diseases Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any skin disease. VAF 21-0960M-1 Amputations Disability Benefits Questionnaire, will gather information related to the claimant’s amputations; VAF 21-0960M-2 Ankle Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of an ankle condition; VAF 21-0960M-4 Elbow and Forearm Conditions Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of an elbow and forearm condition; VAF 21-0960M-5 Flatfoot (pes planus) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of flatfeet (pes planus); VAF 21-0960M-6 Foot Miscellaneous(other than flatfoot (pes planus)) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a foot disability other than flatfeet. VAF 21-0960M-7 Hand and Finger Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a hand and finger condition. VAF 21-0960M-8 Hip and Thigh Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a hip or thigh condition. VAF 21-0960M-9 Knee and Lower Leg Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a knee or lower leg condition. VAF 21-0960M-10 Muscle Injuries Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a muscle injury disability. VAF 21-0960M-12 Shoulder and Arm Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a shoulder or arm condition. VAF 21-0960M-15 Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of temporomandibular joint dysfunction or TMJ. VAF 21-0960M-16 Wrist Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a wrist condition. VAF 21-0960N-2 Eye Conditions Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of an eye condition.
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 potentialduplication; 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 March 23, 2011, pages 16478-16479. 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 750,000 per year for all forms:
VAF 21-0960A-2 – 20,000
VAF 21-0960A-3 – 50,000
VAF 21-0960A-4 – 20,000
VAF 21-0960C-4 – 75,000
VAF 21-0960E-1 –75,000
VAF 21-0960F-1 – 25,000
VAF 21-0960F-2 – 25,000
VAF 21-0960M-1 – 25,000
VAF 21-0960M-2 – 30,000
VAF 21-0960M-4 – 20,000
VAF 21-0960M-5 – 50,000
VAF 21-0960M-6 – 30,000
VAF 21-0960M-7 – 30,000
VAF 21-0960M-8 – 50,000
VAF 21-0960M-9 – 50,000
VAF 21-0960M-10 – 30,000
VAF 21-0960M-12 – 50,000
VAF 21-0960M-15 – 15,000
VAF 21-0960M-16– 40,000
VAF 21-0960N-2 – 40,000
b. Frequency of Response is on occasion for most beneficiaries.
c. Annual burden hours is 317,500 hours:
VAF 21-0960A-2 – 10,000
VAF 21-0960A-3 – 12,500
VAF 21-0960A-4 –10,000
VAF 21-0960C-4 – 37,500
VAR 21-0960E-1 – 18,750
VAF 21-0960F-1- 6,250
VAF 21-0960F-2 – 6,250
VAF 21-0960M-1 – 12,500
VAF 21-0960M-2 – 15,000
VAF 21-0960M-4 – 10,000
VAF 21-0960M-5 – 12,500
VAF 21-0960M-6 – 7,500
VAF 21-0960M-7 – 15,000
VAF 21-0960M-8 – 25,000
VAF 21-0960M-9 – 25,000
VAF 21-0960M-10 – 15,000
VAF 21-0960M-12 – 25,000
VAF 21-0960M-15 – 3,750
VAF 21-0960M-16– 20,000
VAF 21-0960N-2 – 30,000
d. Once the Internet web portal being developed for the public is available for use, private physicians as well as Veterans will be able to readily access DBQs online. VA will also inform the Veteran in VA’s duty to assist letter that the Veteran has the option of submitting a DBQ, which may expedite the processing of his or her claim. The Veteran will be informed that the disability examinations website provides access to the DBQ or that he or she can call VBA’s toll-free number and request that VA send the DBQ. The Veteran will be instructed that if he or she chooses to submit a DBQ in lieu of a VA medical examination, his or her private physician or VA medical provider must complete all applicable sections and sign the form. The DBQ may be submitted via VA’s intranet website, faxed, mailed, or hand delivered. The estimated completion time for each form is as follows:
VAF 21-0960A-2 – 30 minutes
VAF 21-0960A-3 – 15 minutes
VAF 21-0960A-4 – 30 minutes
VAF 21-0960C-4 – 30 minutes
VAR 21-0960E-1 – 15 minutes
VAF 21-0960F-1 – 15 minutes
VAF 21-0960F-2 – 15 minutes
VAF 21-0960M-1 – 30 minutes
VAF 21-0960M-2 – 30 minutes
VAF 21-0960M-4 – 30 minutes
VAF 21-0960M-5 – 15 minutes
VAF 21-0960M-6 – 15 minutes
VAF 21-0960M-7 – 30 minutes
VAF 21-0960M-8 – 30 minutes
VAF 21-0960M-9 – 30 minutes
VAF 21-0960M-10 – 30 minutes
VAF 21-0960M-12 – 30 minutes
VAF 21-0960M-15 – 15 minutes
VAF 21-0960M-16 – 30 minutes
VAF 21-0960N-2 – 45 minutes
e. The total estimated cost to respondents is $4,762,500 (317,500 hours x $15 per hour).
13. This submission does not involve any recordkeeping costs.
14. Estimated Costs to the Federal Government:
a. Processing/Analyzing costs $ 724,246,875
VAF 21-0960-A-2
(GS-13/5 @ $48.35 x 750,000 x 30/60 minutes = $18,131,250)
(GS-12/5 @ $40.66 x 750,000 x 30/60 minutes = $15,247,500)
(GS-9/5 @ $28.04 x 750,000 x 30/60 minutes = $10,515,000)
VAF 21-0960-A-3
(GS-13/5 @ $48.35 x 750,000 x 15/60 minutes = $9,065,625)
(GS-12/5 @ $40.66 x 750,000 x 15/60 minutes = $7,623,750)
(GS-9/5 @ $28.04 x 750,000 x 15/60 minutes = $5,257,500)
VAF 21-0960-A-4
(GS-13/5 @ $48.35 x 750,000 x 30/60 minutes = $18,131,250)
(GS-12/5 @ $40.66 x 750,000 x 30/60 minutes = $15,247,500)
(GS-9/5 @ $28.04 x 750,000 x 30/60 minutes = $10,515,000)
VAF 21-0960-C-4
(GS-13/5 @ $48.35 x 750,000 x 30/60 minutes = $18,131,250)
(GS-12/5 @ $40.66 x 750,000 x 30/60 minutes = $15,247,500)
(GS-9/5 @ $28.04 x 750,000 x 30/60 minutes = $10,515,000)
VAF 21-0960-E-1
(GS-13/5 @ $48.35 x 750,000 x 15/60 minutes = $9,065,625)
(GS-12/5 @ $40.66 x 750,000 x 15/60 minutes = $7,623,750)
(GS-9/5 @ $28.04 x 750,000 x 15/60 minutes = $5,257,500)
VA F 21-0960F-1
(GS-13/5 @ $48.35 x 750,000 x 15/60 minutes = $9,065,625)
(GS-12/5 @ $40.66 x 750,000 x 15/60 minutes = $7,623,750)
(GS-9/5 @ $28.04 x 750,000 x 15/60 minutes = $5,257,500)
VAF 21-0960-F-2
(GS-13/5 @ $48.35 x 750,000 x 15/60 minutes = $9,065,625)
(GS-12/5 @ $40.66 x 750,000 x 15/60 minutes = $7,623,750)
(GS-9/5 @ $28.04 x 750,000 x 15/60 minutes = $5,257,500)
VAF 21-0960-M-1
(GS-13/5 @ $48.35 x 750,000 x 30/60 minutes = $18,131,250)
(GS-12/5 @ $40.66 x 750,000 x 30/60 minutes = $15,247,500)
(GS-9/5 @ $28.04 x 750,000 x 30/60 minutes = $10,515,000)
VAF 21-0960-M-2
(GS-13/5 @ $48.35 x 750,000 x 30/60 minutes = $18,131,250)
(GS-12/5 @ $40.66 x 750,000 x 30/60 minutes = $15,247,500)
(GS-9/5 @ $28.04 x 750,000 x 30/60 minutes = $10,515,000)
VAF 21-0960-M-4
(GS-13/5 @ $48.35 x 750,000 x 30/60 minutes = $18,131,250)
(GS-12/5 @ $40.66 x 750,000 x 30/60 minutes = $15,247,500)
(GS-9/5 @ $28.04 x 750,000 x 30/60 minutes = $10,515,000)
VAF 21-0960-M-5
(GS-13/5 @ $48.35 x 750,000 x 15/60 minutes = $9,065,625)
(GS-12/5 @ $40.66 x 750,000 x 15/60 minutes = $7,623,750)
(GS-9/5 @ $28.04 x 725,000 x 15/60 minutes = $5,257,500)
VAF 21-0960-M-6
(GS-13/5 @ $48.35 x 750,000 x 15/60 minutes = $9,065,625)
(GS-12/5 @ $40.66 x 750,000 x 15/60 minutes = $7,623,750)
(GS-9/5 @ $28.04 x 750,000 x 15/60 minutes = $5,257,500)
VAF 21-0960-M-7
(GS-13/5 @ $48.35 x 750,000 x 30/60 minutes = $18,131,250)
(GS-12/5 @ $40.66 x 750,000 x 30/60 minutes = $15,247,500)
(GS-9/5 @ $28.04 x 750,000 x 30/60 minutes = $10,515,000)
VAF 21-0960-M-8
(GS-13/5 @ $48.35 x 750,000 x 30/60 minutes = $18,131,250)
(GS-12/5 @ $40.66 x 750,000 x 30/60 minutes = $15,247,500)
(GS-9/5 @ $28.04 x 750,000 x 30/60 minutes = $10,515,000)
VAF 21-0960-M-9
(GS-13/5 @ $48.35 x 750,000 x 30/60 minutes = $18,131,250)
(GS-12/5 @ $40.66 x 750,000 x 30/60 minutes = $15,247,500)
(GS-9/5 @ $28.04 x 750,000 x 30/60 minutes = $10,515,000)
VAF 21-0960-M-10
(GS-13/5 @ $48.35 x 750,000 x 30/60 minutes = $18,131,250)
(GS-12/5 @ $40.66 x 750,000 x 30/60 minutes = $15,247,500)
(GS-9/5 @ $28.04 x 750,000 x 30/60 minutes = $10,515,000)
VAF 21-0960-M-12
(GS-13/5 @ $48.35 x 750,000 x 30/60 minutes = $18,131,250)
(GS-12/5 @ $40.66 x 750,000 x 30/60 minutes = $15,247,500)
(GS-9/5 @ $28.04 x 750,000 x 30/60 minutes = $10,515,000)
VAF 21-0960-M-15
(GS-13/5 @ $48.35 x 750,000 x 15/60 minutes = $9,065,625)
(GS-12/5 @ $40.66 x 750,000 x 15/60 minutes = $7,623,750)
(GS-9/5 @ $28.04 x 750,000 x 15/60 minutes = $5,257,500)
VAF 21-0960-M-16
(GS-13/5 @ $48.35 x 750,000 x 15/60 minutes = $9,065,625)
(GS-12/5 @ $40.66 x 750,000 x 15/60 minutes = $7,623,750)
(GS-9/5 @ $28.04 x 750,000 x 15/60 minutes = $5,257,500)
VAF 21-0960-N-2 – 45 minutes
(GS-13/5 @ $48.35 x 750,000 x 45/60 minutes = $27,196,875)
(GS-12/5 @ $40.66 x 750,000 x 45/60 minutes = $22,871,250)
(GS-9/5 @ $28.04 x 750,000 x 45/60 minutes = $15,772,500)
b. Printing and production cost $9,000
c. Total cost to government $ 724,255,875
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 the 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 | 2021-01-31 |