Information Collection

Disability Benefits Questionnaires (Group 3)

IC 196002 under ICR 201201-2900-007 · OMB 2900-0778.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0778 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-0960G-5 Disability Benefits Questionnaires (Group 3)	Form
VA Form 21-0960G-5 Hepatitis, Cirrhosis and other Liver Conditions Disabili 21-0960G-5.pdf www.va.gov/vaforms	Form
VA Form 21-0960G-7 Stomach and Duodenal Conditions (Not including GERD or E 21-0960G-7.pdf www.va.gov/vaforms	Form
VA Form 21-0960M-3 Non-Degenerative Arthritis (Including inflammatory, Auto 21-0960M-3.pdf www.va.gov/vaforms	Form
VA Form 21-0960N-1 Ear Conditions (Including Vestibular and Infectious Cond 21-0960N-1.pdf www.va.gov/vaforms	Form
VA Form 21-0960H-2 Rectum and Anus Conditions Conditions (Including Hemorrh 21-0960H-2.pdf www.va.gov/vaforms	Form
VA Form 21-0960G-6 Peritoneal Adhesions Disability Benefits Questionnaire 21-0960G-6.pdf www.va.gov/vaforms	Form
VA Form 21-0960G-3 Intestinal Conditions (Other than Surgical or Infectious 21-0960G-3.pdf www.va.gov/vaforms	Form
VA Form 21-0960G-4 Intestinal Surgery (Bowel Resection, Colostomy, Ileostom 21-0960G-4.pdf www.va.gov/vaforms	Form
VA Form 21-0960C-5 Central Nervous System and Neuromuscular Diseases 21-0960C-5.pdf www,va,gov/vaforms	Form
VA Form 21-0960G-8 Infectious Intestinal Disorders, Including Bacterial and 21-0960G-8.pdf www.va.gov/vaforms	Form
VA Form 21-0960M-1 Osteomyelitis Disability Benefits Questionnaire 21-0960M-11.pdf www.va.gov/vaforms	Form
VA Form 21-0960K-2 Gynecological Conditions Disability Benefits Questionnai 21-0960K-2.pdf www.va.gov/vaforms	Form
VA Form 21-0960L-2 Sleep Apnea Disability Benefits Questionnaire 21-0960L-2.pdf www.va.gov/vaforms	Form
VA Form 21-0960K-1 Breast Conditions and Disorders Disability Benefits Ques 21-0960K-1.pdf www.va.gov/vaforms	Form
VA Form 21-0960C-8 Headaches (including migraine headaches) Disability Bene 21-0960C-8.pdf www.va.gov/vaforms	Form
VA Form 21-0960G-2 Gallbladder and Pancreas Conditions Disability Benefits 21-0960G-2.pdf www.va.gov/vaforms	Form
VA Form 21-0960G-1 Esophageal Conditions (including gastroesophageal reflus 21-0960G-1.pdf www.va.gov/vaforms	Form
VA Form 21-0960C-9 Multiple Sclerosis (MS) Disability Benefits Questionnair 21-0960C-9.pdf www.va.gov/vaforms	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Disability Benefits Questionnaires (Group 3)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 21-0960G-5	Hepatitis, Cirrhosis and other Liver Conditions Disability Benefits Questionnaire	21-0960G-5.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-7	Stomach and Duodenal Conditions (Not including GERD or Esophageal Disorders) Disability Benefits Questionnaire	21-0960G-7.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-3	Non-Degenerative Arthritis (Including inflammatory, Autoimmune, Crystalline and Infectious Arthritis) and Dysbaric Osteonecrosis Disability Benefits Questionnaire	21-0960M-3.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960N-1	Ear Conditions (Including Vestibular and Infectious Conditions) Disability Benefits Questionnaire	21-0960N-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960H-2	Rectum and Anus Conditions Conditions (Including Hemorrhoids) Disability Benefits Questionnaire	21-0960H-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-6	Peritoneal Adhesions Disability Benefits Questionnaire	21-0960G-6.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-3	Intestinal Conditions (Other than Surgical or Infectious) (Including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis, and Diverticulitis) Disability Benefits Questionnaire	21-0960G-3.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-4	Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire	21-0960G-4.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-5	Central Nervous System and Neuromuscular Diseases	21-0960C-5.pdf	www,va,gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-8	Infectious Intestinal Disorders, Including Bacterial and Parasitic Infections Disability Benefits Questionnaire	21-0960G-8.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-11	Osteomyelitis Disability Benefits Questionnaire	21-0960M-11.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960K-2	Gynecological Conditions Disability Benefits Questionnaire	21-0960K-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960L-2	Sleep Apnea Disability Benefits Questionnaire	21-0960L-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960K-1	Breast Conditions and Disorders Disability Benefits Questionnaire	21-0960K-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-8	Headaches (including migraine headaches) Disability Benefits Questionnaire	21-0960C-8.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-2	Gallbladder and Pancreas Conditions Disability Benefits Questionnaire	21-0960G-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-1	Esophageal Conditions (including gastroesophageal reflus disease (GERD), hiatal hernia and other esophageal disorders) Disability Benefits Questionnaire	21-0960G-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-9	Multiple Sclerosis (MS) Disability Benefits Questionnaire	21-0960C-9.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: Compensation, Pension, Education, and Rehabilitation RecordsÂVA (58VA21/22/28)

FR Citation: 74 FR 117

Number of Respondents: 350,000

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	Previously Approved
Annual Number of Responses for this IC	350,000	350,000
Annual IC Time Burden (Hours)	102,500	102,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.