Statement in Support of Claim for Service Connection for PTSD (VA Form 21-0781), Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault (21-0781a)

Forms and Documents

Document Name	Status
Form VA Form 21-0781a Statement in Support of Claim for Service Connection for PTSD (21-0781), Statement in Support of Claim for Service Connection for PTSD(VA Form 21-0781a) Form	Modified
2900-0659SupportState.docx Supporting Statement A	2014-04-29

IC Document Collections

IC ID	Document Title	Status
28937	Statement in Support of Claim for Service Connection for PTSD (21-0781), Statement in Support of Claim for Service Connection for PTSD(VA Form 21-0781a) Form	Modified

ICR Details

OMB Control No: 2900-0659	ICR Reference No: 201309-2900-018
Status: Historical Active	Previous ICR Reference No: 201101-2900-003
Agency/Subagency: VA	Agency Tracking No: 2900-0659 VBA-COMP-NK
Title: Statement in Support of Claim for Service Connection for PTSD (VA Form 21-0781), Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault (21-0781a)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/05/2014
	Date Received in OIRA: 06/02/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2017	36 Months From Approved	08/31/2014
Responses	15,240	0	15,240
Time Burden (Hours)	17,780	0	17,780
Cost Burden (Dollars)	0	0	0

---

Abstract: VA Forms 21-0781 and 21-0781a are used to gather information about stressful incidents in service from veterans claiming compensation for PTSD. The forms request the information that is necessary for VA to conduct meaningful research of records in order to assist claimants in obtaining credible supporting evidence supporting evidence that the incidents occurred. Without this collection of information, VA would not fulfill its statutory duty to assist claimants and would be unable to properly authorize benefits.

---

Authorizing Statute(s): US Code: 38 USC 5107a Name of Law: Claimant responsibility; benefit of the doubt
   US Code: 38 USC 5101 Name of Law: Claims and Forms
   US Code: 38 USC 5103a Name of Law: Duty to assist claimants
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 11	01/16/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 94	05/15/2014
Did the Agency receive public comments on this ICR? Yes

---

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

IC Title	Form No.	Form Name
Statement in Support of Claim for Service Connection for PTSD (21-0781), Statement in Support of Claim for Service Connection for PTSD(VA Form 21-0781a)	VA Form 21-0781a, VA Form 21-0781	Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder Secondary to Personal Assault ,   Statement in Support of Claim for Service Connection for Post Traumatic Stress Disorder (PTSD)

---

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	15,240	15,240	0	0	0	0
Annual Time Burden (Hours)	17,780	17,780	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:

---

Annual Cost to Federal Government: $471,179

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

---

Common Form ICR:  No

---

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: 06/02/2014

---