Supporting Statement for
VAF 21-0960a-1, Ischemic Heart Disease (IHD) Disability Benefits Questionnaire
VAF 21-0960b-1, Hairy Cell and Other B-cell Leukemias Disability Benefits Questionnaire
VAF 21-0960-1c, Parkinson's Disease Disability Benefits Questionnaire
(2900-0749)
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. VA Form 21-0960 series will be used for disability compensation or pension claims which require an examination.
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 benenfits. The Disability Benefit Questionnaire title will include the name of the specific disability for which it will gather information. Form 21-0960a-1, Ischemic Heart Disease (IHD) Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of ischemic heart disease. Form 21-0960b-1, Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of Leukemia. Form 21-0960c-1, Parkinsons Disease Disability Benefits Questionnaire will gather specific information related to the claimant’s diagnosis of Parkinsons Disease.
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 13, 2013, page 35661. VA received one comment from Swords to Plowshares requesting VA develop a section on the information collection or stand alone information collection for medical opinions. VA referred Swords to Plowshares to earlier responses on prior information collections of the same subject, which specifically addresses VA’s consideration of a standalone Medical Opinion DBQ for public release at a later date.
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 Vocational Rehabilitation and Employment Records-VA (58VA21/22/28),” published at 74 FR 29275 on June 19, 2009, and last amended at 75 FR 22187 (April 27, 2010).
11. There are no questions of a sensitive nature.
12. Estimate of Information Collection Burden.
a. Number of Respondents is estimated at:
Ischemic Heart Disease (IHD) Disability Benefits Questionnaire, VA Form 21-0960A-1 – 55,000.
Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire, VA Form 21-0960B-1 – 2,000.
Parkinson’s Disease Disability Benefits Questionnaire, VA Form 21-0960C-1 – 5,000.
b. Frequency of Response is on occasion for most beneficiaries.
c. Annual burden:
Ischemic Heart Disease (IHD) Disability Benefits Questionnaire, VA Form 21-0960A-1 – 13,750.
Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire, VA Form 21-0960B-1 – 500.
Parkinson’s Disease Disability Benefits Questionnaire, VA Form 21-0960C-1 – 1,250.
.d. The estimated completion time is15 minutes for each form.
e. The total estimated cost to respondents is $372,000 (15,500 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 $4,454,390
(GS-13/5 @ $48.35 x 62,000 x 30/60 minutes = $1,498,850)
(GS-12/5 @ $40.66 x 62,000 x 60/60 minutes = $2,520,920)
(GS-9/5 @ $28.04 x 62,000 x 15/60 minutes = $434,620)
b. Printing and production cost $5,500
c. Total cost to government $4,459,890
15. This is an approved information collection.
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.
| File Type | application/msword |
| File Title | SF 83 SS VAF 21-8926 |
| Author | Veterans Benefits Administrat |
| Last Modified By | Kessinger, Nancy, VBAVACO |
| File Modified | 2014-01-30 |
| File Created | 2014-01-30 |