OMB21-0960m-3(3-31-14)

Supporting Statement for

VAF 21-0960M-3

Non-Degenerative Arthritis (including inflammatory, autoimmune, crystalline and infectious arthritis) and Dysbaric Osteonecrosis 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), Rules and Regulations, 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 21-0960M-3, Non-Degenerative Arthritis (including inflammatory, autoimmune, crystalline and infectious arthritis) and Dysbaric Osteonecrosis Disability Benefits Questionnaire 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 initial Information Collection Request (ICR) for the VAF 21-0960 series (71 forms) was consolidated under five Office of Management and Budget (OMB) control numbers (2900-0749, 2900-07769, 2900-0778, 2900-0779, and 2900-0781). OMB Control Number 2900-0778, which expires March 15, 2015, currently contains VA Form 21-0960M-3, Non-Degenerative Arthritis (including inflammatory, autoimmune, crystalline and infectious arthritis) and Dysbaric Osteonecrosis Disability Benefits Questionnaire.

VA proposes to remove this information collection (IC) from control number 2900-0778 and have it assigned a new individual control number. VA will retain all other ICs under OMB control number 2900-0778 until pending substantive revisions are complete. At which time, VA will request separate OMB control numbers for each IC in the VA Form 21-0960 series and discontinue OMB control number 2900-0778.

This change is necessary to provide VA with the flexibility to modify each form on an individual basis instead of limiting the changes to the original five groupings. VA needs the maximum flexibility because the content of the form is influenced by a multitude of unpredictable forces outside its control. As such, VA needs to maximize its ability to modify the forms consistent with the form contents’ dynamic environment. This change will not increase the respondent burden.

2. The form 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.  VAF 21-0960M-3, Non-Degenerative Arthritis (including inflammatory, autoimmune, crystalline and infectious arthritis) and Dysbaric Osteonecrosis Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a non-degenerative arthritis or osteonecrosis 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.

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 means 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 states in pertinent part that in a claim for disability compensation, VA will provide a medical examination or obtain a medical opinion if 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 June 17, 2013, Volume 78, No. 116, pages 36305-36306. Two comments were received in response to this notice. Comments were received from Michelle LaVerne Francis-Lezcano regarding various medical conditions and symptoms that were not generally related to this information collection. Comments were received from William Thomas Duncan, Jr., regarding various medical conditions and symptoms that were not generally related to this information collection.

This notice solicits comments on information needed to adjudicate claims for VA disability benefits related to a diagnosis of Non-Degenerative Arthritis and Dysbaric Osteonecrosis. The comments received were specifically about individual symptoms and disabilitis and not related to the information collection itself. Each commenter was instructed to contact their local VA Regional Office for any further questions or comments regarding their specific claims for arthritis along with the appropriate contact information.

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 100,000 per year

b. Frequency of Response is on occasion for most beneficiaries.

c. Annual burden hours is 25,000 hours:

d. The estimated completion time for VAF 21-0960M-3 is 15 minutes

e. According to the U.S. Bureau of Labor Statistics Average Hourly Earnings, the cost to the respondent is $24, making the total cost to the respondents an extimated $600,000. (25,000 burden hours X $24 per hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $ 5,852,500

(GS-13/5 @ $48.35 x 100,000 x 30/60 minutes = $ 2,417,500)

(GS-12/5 @ $40.66 x 100,000 x 30/60 minutes = $ 2,033,000)

(GS-09/5 @ $28.04 x 100,000 x 30/60 minutes = $ 1,402,000)

b. Printing and production cost $9,000

c. Total cost to government $ 5,861,500

15. This is a new information collection. However, the information collected in this request is currently approved under OMB Control Number 2900-0778.

16. The information collection is not for publication or tabulation use.

17. We are not seeking approval to omit the expiration date for OMB approval.

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.