2900-0779 (Group 1)(10-22-14)

Supporting Statement for:

(2900-0779)

VAF 21-0960B-2	Hematologic and Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire
VAF 21-0960C-2	Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease) Disability Benefits Questionnaire
VAF 21-0960C-10	Peripheral Nerve Conditions (Not Including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire
VAF 21-0960I-1	Persian Gulf and Afghanistan Infectious Diseases Disability Benefits Questionnaire
VAF 21-0960I-6	Tuberculosis Disability Benefits Questionnaire
VAF 21-0960J-1	Kidney Conditions (Nephrology) Disability Benefits Questionnaire
VAF 21-0960J-2	Male Reproductive Organ Conditions Disability Benefits Questionnaire
VAF 21-0960J-3	Prostate Cancer Disability Benefits Questionnaire
VAF 21-0960P-1	Eating Disorders Disability Benefits Questionnaire
VAF 21-0960P-2	Mental Disorders (other than PTSDand Eating Disorders) Disability Benefits Questionnaire
VAF 21-0960P-3	Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire

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. VA Form 21-0960 series will be used for disability compensation or pension claims which require an examination.

VA requested removal of VAF 21-0960M-13, Neck (Cervical Spine) Disability Benefits Questionnaire and VAF 21-0960M-14, Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire from OMB Control No. 2900-0779 and have them assigned new individual control numbers. VA will retain all other ICs under OMB control number 2900-0779 until pending revisions are complete. At which time, VA will request separate OMB control numbers for each IC in the VA Form 21-0960 series under OMB Control Number 2900-0779.

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.

The DBQs listed in the above table have been updated with the following language in the Note to Physician block; “VA reserves the right to confirm the authenticity of ALL DBQs completed by private health care providers.” This sentence is located at the end of the paragraph.

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. VAF 21-0960B-2, Hematologic and Lymphatic Conditions, Including LeukemiaDisability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any hematologic or lymphatic condition; VAF 21-0960C-2, Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of amyotrophic lateral sclerosis; VAF 21-0960C-10, Peripheral NerveConditions (Not Including Diabetic Sensory-Motor Peripheral neuropathy) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a peripheral nerve disorder; VAF 21-0960I-1, Persian Gulf and Afghanistan Infectious Diseases Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of an infectious disease due to service in the Persian Gulf or Afghanistan; VAF 210960-I-6, Tuberculosis Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of tuberculosis; VAF 21-0960J-1, Kidney Conditions (Nephrology) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of kidney disease; VAF 21-0960J-2, Male Reproductive Organ Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a condition affecting the male reproductive organ; VAF 21-0960J-3, Prostate Cancer Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of prostate cancer; VAF 21-0960P-1, Eating Disorders Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of an eating disorder; VAF 21-0960P-2, Mental Disorders (other than PTSDand Eating Disorders) Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of any mental disorder with the exception of PTSD; VAF 21-0960P-3, Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of PTSD.

3. This VA Form 21-0960 series is available on the One-VA Website in a fillable electronic format. VBA is currently hosting this form on a secure server and does not currently have the technology in place to allow for the complete submission of the form. Validation edits are performed to assure data integrity. Efforts within VA are underway to provide a mechanism to allow the information to be submitted electronically with a recognized signature technology. There currently is no utility process in place that will allow the data submitted on the form to be incorporated with an existing centralized legacy database.

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.

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.

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 July 17, 2014, Volume 79, No. 137, pages 41743 and 41744. One comment was received in response to this notice.

Comment:

A comment received from Daniel Umlauf, QTC-A Lockheed-Martin Company proposed changes to each of the DBQs that make up Group I.  The proposed changes consist of both substantive and non-substantive changes.

Response:

VA is not currently making substantive changes to these DBQs; the purpose of this publication is to renew the OMB control number only.  Mr. Umlauf had no other comments on these DBQs under review.  Regarding any future substantive changes to these DBQs, VA invites Mr. Umlauf to submit comments on the content of the form at the time of publication.

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.

1. Number of Respondents is estimated at 307,000 per year for all forms:

1. VAF 21-0960B-2 - 10,000

2. VAF 21-0960C-2 – 2,000

3. VAF 21-0960C-10 – 55,000

4. VAF 21-0960I-1 – 50,000

5. VAF 21-0960I-6 – 5,000

6. VAF 21-0960J-1 – 25,000

7. VAF 21-0960J-2 – 25,000

8. VAF 21-0960-J-3 - 25,000

9. VAF 21-0960P-1 – 5,000

10. VAF 21-0960P-2 – 50,000

11. VAF 21-0960P-3 – 55,000

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

3. The average annual burden hours is 127,917 hours.

4. The estimated completion time for each form is as follows with an average of 25 minutes:

1. VAF 21-0960B-2 – 15 minutes

2. VAF 21-0960C-2 – 30 minutes

3. VAF 21-0960C-10 – 45 minutes

4. VAF 21-0960I-1 – 15 minutes

5. VAF 21-0960I-6 – 30 minutes

6. VAF 21-0960J-1 – 30 minutes

7. VAF 21-0960J-2 – 15 minutes

8. VAF 21-0960J-3 - 15 minutes

9. VAF 21-0960P-1 – 15 minutes

10. VAF 21-0960P-2 – 30 minutes

11. VAF 21-0960P-3 – 30 minutes

5. 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 estimated $3,070,008. (127,917 burden hours x $24 per hour).

13. This submission does not involve any recordkeeping costs. VA does not anticipate any costs associated with the completion of these form by third parties, such as physicians. The completion of a DBQ by a private physician falls within the regulatory exception, as it is part of the customary practice of a healthcare provider and is therefore not a part of the annual cost burden for recordkeeping.

14. Estimated Costs to the Federal Government:

1. Processing/Analyzing costs $17,212,790

VAF 21-0960-B-2

(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875)

(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650)

(GS-9/5 @ $28.04 x 10,000 x 15/60 minutes = $70,100)

VAF 21-0960-C-2

(GS-13/5 @ $48.35 x 2,000 x 30/60 minutes = $48,350)

(GS-12/5 @ $40.66 x 2,000 x 30/60 minutes = $ 40,660)

(GS-9/5 @ $28.04 x 2,000 x 30/60 minutes = $ 28,040)

VAF 21-0960-C-10

(GS-13/5 @ $48.35 x 55,000 x 45/60 minutes = $ 1,994,438)

(GS-12/5 @ $40.66 x 55,000 x 45/60 minutes = $ 1,677,225)

(GS-9/5 @ $28.04 x 55,000 x 45/60 minutes = $ 1,156,650)

VAF 21-0960-I-1

(GS-13/5 @ $48.35 x 50,000 x 15/60 minutes = $ 604,375)

(GS-12/5 @ $40.66 x 50,000 x 15/60 minutes = $ 508,250)

(GS-9/5 @ $28.04 x 50,000 x 15/60 minutes = $ 35,050)

VAF 21-0960-I-6

(GS-13/5 @ $48.35 x 5,000 x 30/60 minutes = $ 120,875)

(GS-12/5 @ $40.66 x 5,000 x 30/60 minutes = $ 101,650)

(GS-9/5 @ $28.04 x 5,000 x 30/60 minutes = $ 70,100)

VAF 21-0960-J-1

(GS-13/5 @ $48.35 x 25,000 x 30/60 minutes = $ 604,375)

(GS-12/5 @ $40.66 x 25,000 x 30/60 minutes = $ 508,250)

(GS-9/5 @ $28.04 x 25,000 x 30/60 minutes = $ 350,500)

VAF 21-0960-J-2

(GS-13/5 @ $48.35 x 25,000 x 15/60 minutes = $302,188)

(GS-12/5 @ $40.66 x 25,000 x 15/60 minutes = $254,1253)

(GS-9/5 @ $28.04 x 25,000 x 15/60 minutes = $175,250)

VAF 21-0960-J-3

(GS-13/5 @ $48.35 x 25,000 x 15/60 minutes = $302,188)

(GS-12/5 @ $40.66 x 25,000 x 15/60 minutes = $ 254,125)

(GS-9/5 @ $28.04 x 25,000 x 15/60 minutes = $175,250)

VAF 21-0960-O-1

(GS-13/5 @ $48.35 x 25,000 x 15/60 minutes = $302,188)

(GS-12/5 @ $40.66 x 25,000 x 15/60 minutes = $ 254,125)

(GS-9/5 @ $28.04 x 25,000 x 15/60 minutes = $175,250)

VAF 21-0960-P-1

(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $302,188)

(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $ 254,125)

(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $175,250)

VAF 21-0960-P-2

(GS-13/5 @ $48.35 x 50,000 x 30/60 minutes = $1,208,750)

(GS-12/5 @ $40.66 x 50,000 x 30/60 minutes = $ 1,016,500)

(GS-9/5 @ $28.04 x 50,000 x 30/60 minutes = $ 701,000)

VAF 21-0960-P-3

(GS-13/5 @ $48.35 x 55,000 x 30/60 minutes = $1,329,625)

(GS-12/5 @ $40.66 x 55,000 x 30/60 minutes = $ 1,118,150)

(GS-9/5 @ $28.04 x 55,000 x 30/60 minutes = $ 771,100)

2. Printing and production cost $1,549,151

3. Total cost to government $18,761,941

15. The respondent burden is decreased because VA removed two collections from this group. With the exception of the expiration date placeholder, there are no substantive revisions to the remaining information collections.

The DBQs listed in the above table have been updated with the following language in the Note to Physician or Psychiatrist block; “VA reserves the right to confirm the authenticity of ALL DBQs completed by private health care providers.” This sentence is located at the end of the paragraph. This change is a nonsubstantive change.

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 collection of information does not employ statistical methods.