Employment Questionnaire (21-4140 & 21-4140-1)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 21-4140 Employment Questionnaire (21-4140 & 21-4140-1)	Form	Modified	Repair queued
30-Day FRN - 2900-0079 (2014).pdf	Supplementary Document	Uploaded 2014-09-26	Available
60-Day FRN - 2900-0079 (2014).pdf	Supplementary Document	Uploaded 2014-06-17	Available
Supporting Statement for 2900-0079, VAF 21-4140 and 21-4140-1 (8-26-14).docx	Supporting Statement A	Uploaded 2014-08-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28229	Employment Questionnaire (21-4140 & 21-4140-1)	Form	Modified

ICR Details

OMB Control No: 2900-0079	ICR Reference No: 201404-2900-016
Status: Historical Active	Previous ICR Reference No: 201104-2900-025
Agency/Subagency: VA	Agency Tracking No: 2900-0079 VBA-COMP-YM
Title: Employment Questionnaire (21-4140 & 21-4140-1)
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: 12/23/2014
	Date Received in OIRA: 10/03/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2017	36 Months From Approved	01/31/2015
Responses	130,000	0	130,000
Time Burden (Hours)	10,833	0	10,833
Cost Burden (Dollars)	0	0	0

---

Abstract: VA Forms 21-4140 and 21-4140-1 are to be used to gather information that is necessary to determine a recipient's continued entitlement to individual unemployability benefits. Without information about recipients' employment, VA would not be able to determine continued entitlement, and overpayments would result.

---

Authorizing Statute(s): US Code: 38 USC 5317 Name of Law: Use of income information from other agencies: notice and verification
   US Code: 38 USC 501 Name of Law: Rules and regulations
  

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 33813	06/12/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 51655	08/29/2014
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Employment Questionnaire (21-4140 & 21-4140-1)	21-4140, 21-4140-1	Employment Questionnaire ,   Employment Questionnaire

---

ICR Summary of Burden

table that charts list 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	130,000	130,000	0	0	0	0
Annual Time Burden (Hours)	10,833	10,833	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: $3,084,383

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: 10/03/2014

---