Disability Benefits Questionnaires (Group 1)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 21-0960M-1 Neck (cervical spine) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960B-2 Hematologic and Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960P-1 Eating Disorders Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960J-1 Kidney Conditions (Nephrology) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960C-1 Peripheral Nerves Conditions (Not including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960C-2 Amotrophic Lateral Sclerosis (Lou Gehrig's Disease) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960J-2 Male Reproductive Organ Conditions Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960P-2 Mental Disorders (Other than PTSD and Eating Disorders) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960P-3 Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960J-3 Prostate Cancer Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960I-1 Persian Gulf and Afghanistan Infectious Diseases Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960M-1 Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960I-6 Tuberculosis Disability Benefits Questionnaire	Form	Modified	Available
Second Supplementary document for ROCIS (Group 1) - 101300JAN12.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2012-01-11	Available
Supplementary document for ROCIS (Group 1) - 151250DEC.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2011-12-15	Repair queued
VAF21-0960 DBQs Group1.docx	Supporting Statement A	Uploaded 2011-06-09	Available
21-0960P-4.pdf	Supplementary Document	Uploaded 2011-02-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Neck (cervical spine) Disability Benefits Questionnaire
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Hematologic and Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Eating Disorders Disability Benefits Questionnaire
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Kidney Conditions (Nephrology) Disability Benefits Questionnaire
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Peripheral Nerves Conditions (Not including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Amotrophic Lateral Sclerosis (Lou Gehrig's Disease) Disability Benefits Questionnaire
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Male Reproductive Organ Conditions Disability Benefits Questionnaire
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Mental Disorders (Other than PTSD and Eating Disorders) Disability Benefits Questionnaire
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Prostate Cancer Disability Benefits Questionnaire
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Persian Gulf and Afghanistan Infectious Diseases Disability Benefits Questionnaire
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire
195776	Disability Benefits Questionnaires (Group I )	Form	Modified	Tuberculosis Disability Benefits Questionnaire

ICR Details

OMB Control No: 2900-0779	ICR Reference No: 201201-2900-006
Status: Historical Active	Previous ICR Reference No: 201112-2900-016
Agency/Subagency: VA	Agency Tracking No: 2900-0779
Title: Disability Benefits Questionnaires (Group 1)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/26/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/12/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2014	11/30/2014	11/30/2014
Responses	407,000	0	407,000
Time Burden (Hours)	213,500	0	213,500
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 21-0960 series (Group I) will be used to determine validity for disability compensation or pension claims which require an examination.

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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 31	02/15/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 109	06/07/2011
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 I )	VA Form 21-0960M-13, VA Form 21-0960B-2, VA Form 21-0960P-3, VA Form 21-0960P-2, VA Form 21-0960J-2, VA Form 21-0960M-14, VA Form 21-0960J-3, VA Form 21-0960I-1, VA Form 21-0960C-2, VA Form 21-0960I-6, VA Form 21-0960J-1, VA Form 21-0960C-10, VA Form 21-0960P-1	Tuberculosis Disability Benefits Questionnaire ,   Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire ,   Persian Gulf and Afghanistan Infectious Diseases Disability Benefits Questionnaire ,   Prostate Cancer Disability Benefits Questionnaire ,   Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire ,   Mental Disorders (Other than PTSD and Eating Disorders) Disability Benefits Questionnaire ,   Male Reproductive Organ Conditions Disability Benefits Questionnaire ,   Amotrophic Lateral Sclerosis (Lou Gehrig's Disease) Disability Benefits Questionnaire ,   Peripheral Nerves Conditions (Not including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire ,   Kidney Conditions (Nephrology) Disability Benefits Questionnaire ,   Eating Disorders Disability Benefits Questionnaire ,   Hematologic and Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire ,   Neck (cervical spine) 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	407,000	407,000	0	0	0	0
Annual Time Burden (Hours)	213,500	213,500	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $316,044,000

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: 01/12/2012

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