Supporting Statement for:
(2900-XXXX)
VA Form 21-0964 |
Statement in Support of Claim for Disability and Related Compensation Benefits Due to Exposure |
A. Justification
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. Title 38 U.S.C. 5101(a) provides that a specific claim in the form provided by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by the Secretary. As of March 24, 2015, RIN 2900-AO81, Standard Claims and Appeals Forms, will take effect. This new rule (approved by OMB on September 25, 2014) requires all claims for benefits to be submitted on an application or forms prescribed by the Secretary.
Since all claims are now required to be on an application or other prescribed form, VA is codifying its regulations to standardize the use of all VA forms, including the creation of; VA Form 21-0964, Statement in Support of Claim for Disability and Related Compensation Benefits Due to Exposure. This form is intended to be completed with VA Form 21-526, Veterans Application for Compensation and/or Pension or VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits.
VA Form 21-0964 is a ‘new’ collection, used to gather information related to claims involving certain exposure types. These exposure types are; asbestos, cold weather injury, Gulf War/environmental hazards, herbicides, ionizing radiation, mustard gas and/or lewisite, Hepatitis C, and water contamination at Camp Lejeune. When VA develops claims for any of these exposures, there are certain locations in which the VA concedes a Veteran serving in that area was exposed. Without this information, determination of entitlement would not be possible. The information will be used only when a Veteran claims a disability related to one of these exposure types.
VA Form 21-0964 will be available on the One-VA Website in a fillable electronic format and VBA will host this form on a secure server. VA has previously requested evidence of exposure from claimants to assist in verifying and quantitatively assessing claims of disabilities due to exposures, however, this information has never been consolidated into one data collection, as it is now on VA Form 21-0964. 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.
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.
The collection of information does not involve small businesses or entities.
This form is being developed into a “user friendly” form, incorporating plain English, to comply with the President’s Memorandum of June 1, 1998, Plain Language in Government Writing. Without this data collection, determination of entitlement due to exposure, would not be possible.
There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.
The Department notice (60-day) was published in the Federal Register on:
April 16, 2014, Vol. 79, No. 73, pages 21518 and 21519.
One comment received.
Regarding
the Federal Register notice, "Proposed Information Collection
Activity: Proposed Collection (Statement in Support of Claim for
Disability and Related Compensation Benefits Due to Exposure) Comment
Request:"
The C-123 Veterans Association urges
the Department of Veterans Affairs to insure that all epidemiological
data, once purged of privacy information, obtained through this
effort be integrated into the various exposure registries maintained
by the Department. Further, the Association notes that completion of
the form online is difficult when a Veteran is claiming both an
exposure and a separate illness or injury.
Response:
VA has an exposure registry that is shared by VA and the Department of Defense. The data collected from VA Form 21-0964 will feed directly into the registry and our existing corporate records. Used together, the registry and form will promote electronic and timelier processing of disabilities claimed due to exposure.
VA Form 21-0964 was developed to be used in conjunction with other approved applications, such as VA Forms 21-526 or 21-526EZ. Service connection may be granted for a disability related to exposure during military service if evidence demonstrates that the Veteran was exposed in service and the exposure resulted in a disease usually associated with such exposure. Since exposure, in itself, is not a disability, then disabilities such as illness or injury will need to be documented on application forms such as VA Forms 21-526 or 21-526EZ.
No payments or gifts to respondents have been made under this collection of information.
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 (June 19, 2009).
There are no questions of a sensitive nature.
Estimate of Information Collection Burden. The number of yearly respondent totals is estimated based on the number of respondents claiming disabilities due to exposure, claimed on applications or other prescribed forms.
Number of yearly respondents totals = 20,000:
20,000 for VA Form 21-0964
Frequency of Response is one time.
Annual burden total = 6,667:
6,667 for VA Form 21-0964
The estimated completion time is:
20 minutes for VA Form 21-0964
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 $160,008 (6,667 burden hours x $24 per hour).
This submission does not involve any recordkeeping costs.
Estimated Costs to the Federal Government:
a. Processing/Analyzing costs $152,000
(GS - 9/5 @ $22.80 x 20,000 x 20/60 minutes = $152,000)
b. Total cost to government $152,000
VA Form 21-0964 is a ‘new’ collection, used to gather information related to claims involving certain exposure types. These exposure types are; asbestos, cold weather injury, Gulf War/environmental hazards, herbicides, ionizing radiation, mustard gas and/or lewisite, Hepatitis C, and water contamination at Camp Lejeune. When VA develops claims for any of these exposures, there are certain locations in which the VA concedes a Veteran serving in that area was exposed. Without this information, determination of entitlement would not be possible. The information will be used only when a Veteran claims a disability related to one of these exposure types.
The expiration date placeholder has been added to the form.
The information collection is not for publication or tabulation use.
We are not seeking approval to omit the expiration date for OMB approval.
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/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |