Information Collection

Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident (21P-4176)

IC 28285 under ICR 201405-2900-002 · OMB 2900-0104.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 21P-4176 Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident (21P-4176)	Form
21P-4176 Report of Accidental Injury in Support of Claim for Comp 21P-4176.pdf www.va.gov/vaforms/	Form

IC Title:

Agency IC Tracking Number:

2900-0104 VBA-P&F-DB

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.301

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21P-4176	Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident	21P-4176.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,408

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,408	4,408
Annual IC Time Burden (Hours)	2,204	2,204
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.