Disability Benefits Questionnaires (Group 3)

Forms and Documents

Document Name	Status
Form VA Form 21-0960G-5 Disability Benefits Questionnaires (Group 3) Form	Modified
Second Supplementary document for ROCIS (Group 3) - 101325JAN12.doc Justification for No Material/Nonsubstantive Change	2012-01-11
Supplementary document for ROCIS (Group 3) - 151250DEC.doc Justification for No Material/Nonsubstantive Change	2011-12-15
DBQ Group3_Supplemental_Statement_(07-25-11)11[1].doc Supplementary Document	2011-07-25
Supporting_Statement_for_VAF_21-0960_Group_3_(07-25-11)[1].docx Supporting Statement A	2011-07-25

IC Document Collections

IC ID	Document Title	Status
196002	Disability Benefits Questionnaires (Group 3) Form	Modified

ICR Details

OMB Control No: 2900-0778	ICR Reference No: 201201-2900-007
Status: Historical Active	Previous ICR Reference No: 201112-2900-015
Agency/Subagency: VA	Agency Tracking No: 2900-0778
Title: Disability Benefits Questionnaires (Group 3)
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: 01/23/2012
	Date Received in OIRA: 01/12/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2014	11/30/2014	11/30/2014
Responses	350,000	0	350,000
Time Burden (Hours)	102,500	0	102,500
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 73	04/15/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 118	06/20/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Disability Benefits Questionnaires (Group 3)	VA Form 21-0960G-4, VA Form 21-0960C-5, VA Form 21-0960G-8, VA Form 21-0960H-2, VA Form 21-0960G-5, VA Form 21-0960G-7, VA Form 21-0960M-11, VA Form 21-0960K-2, VA Form 21-0960L-2, VA Form 21-0960K-1, VA Form 21-0960C-8, VA Form 21-0960G-2, VA Form 21-0960C-9, VA Form 21-0960G-1, VA Form 21-0960M-3, VA Form 21-0960N-1, VA Form 21-0960G-3, VA Form 21-0960G-6	Hepatitis, Cirrhosis and other Liver Conditions Disability Benefits Questionnaire ,   Stomach and Duodenal Conditions (Not including GERD or Esophageal Disorders) Disability Benefits Questionnaire ,   Non-Degenerative Arthritis (Including inflammatory, Autoimmune, Crystalline and Infectious Arthritis) and Dysbaric Osteonecrosis Disability Benefits Questionnaire ,   Ear Conditions (Including Vestibular and Infectious Conditions) Disability Benefits Questionnaire ,   Rectum and Anus Conditions Conditions (Including Hemorrhoids) Disability Benefits Questionnaire ,   Peritoneal Adhesions Disability Benefits Questionnaire ,   Intestinal Conditions (Other than Surgical or Infectious) (Including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis, and Diverticulitis) Disability Benefits Questionnaire ,   Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire ,   Central Nervous System and Neuromuscular Diseases ,   Infectious Intestinal Disorders, Including Bacterial and Parasitic Infections Disability Benefits Questionnaire ,   Osteomyelitis Disability Benefits Questionnaire ,   Gynecological Conditions Disability Benefits Questionnaire ,   Sleep Apnea Disability Benefits Questionnaire ,   Breast Conditions and Disorders Disability Benefits Questionnaire ,   Headaches (including migraine headaches) Disability Benefits Questionnaire ,   Gallbladder and Pancreas Conditions Disability Benefits Questionnaire ,   Esophageal Conditions (including gastroesophageal reflus disease (GERD), hiatal hernia and other esophageal disorders) Disability Benefits Questionnaire ,   Multiple Sclerosis (MS) Disability Benefits Questionnaire

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ICR Summary 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	350,000	350,000	0	0	0	0
Annual Time Burden (Hours)	102,500	102,500	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: $310,923,070

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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