Disability Benefits Questionnaires (Group 4)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 21-0960N-4 Sinusitis/Rhinitis and Other Diseases of the Nose, Throat, Larynx, Pharynx Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960Q-1 Chronic Fatigue Syndrome Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960N-3 Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960L-1 Respiratory Conditions (Other Than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960J-4 Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960I-5 Nutritional Deficiencies Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960I-4 Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960I-3 Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960I-2 HIV - Related Illnesses Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960H-1 Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960E-3 Thyroid and Parathyroid Conditions Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960E-2 Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960D-1 Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960C-1 Seizure Disorders (Epilepsy) Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960C-7 Fibromyalgia Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960C-6 Narcolepsy Disability Benefits Questionnaire	Form	Modified	Available
Form VA Form 21-0960C-3 Cranial Nerve Conditions Disability Benefits Questionnaire	Form	Modified	Available
VA-2014-VACO-0001-0304-A1, Comments (10-28-14).xls	Public Comments	Uploaded 2014-10-27	Repair queued
VA-2014-VACO-0001-0304, Group4, comment.html	Public Comments	Uploaded 2014-10-27	Repair queued
201406-2900-015_OMB2900-0781(Group 4 DBQ) (7-7-15).docx	Supporting Statement A	Uploaded 2015-07-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Sinusitis/Rhinitis and Other Diseases of the Nose, Throat, Larynx, Pharynx Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Chronic Fatigue Syndrome Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Respiratory Conditions (Other Than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Nutritional Deficiencies Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	HIV - Related Illnesses Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Thyroid and Parathyroid Conditions Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Seizure Disorders (Epilepsy) Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Fibromyalgia Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Narcolepsy Disability Benefits Questionnaire
196008	Disability Benefits Questionnaires (Group 4)	Form	Modified	Cranial Nerve Conditions Disability Benefits Questionnaire

ICR Details

OMB Control No: 2900-0781	ICR Reference No: 201406-2900-015
Status: Historical Active	Previous ICR Reference No: 201101-2900-014
Agency/Subagency: VA	Agency Tracking No: 2900-0781 VBA-COMP-DB
Title: Disability Benefits Questionnaires (Group 4)
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: 07/09/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/05/2015
Terms of Clearance: This ICR is approved for one year. Upon the next submission of this ICR for OMB approval, VA must address all substantive and non-substantive comments that were submitted by Lockheed Martin in response to the Federal Register Notice for this ICR that was published on August 15, 2014.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2016	36 Months From Approved	07/31/2015
Responses	160,000	0	160,000
Time Burden (Hours)	53,750	0	56,250
Cost Burden (Dollars)	0	0	0

---

Abstract: These forms are being created to assist veteran's who require a disability examination in support of a claim for VA benefits. Forms will be used to record the findings of the examining physician.

---

Authorizing Statute(s): US Code: 38 USC 501(a) 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 167	08/28/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 243	12/18/2014
Did the Agency receive public comments on this ICR? Yes

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Disability Benefits Questionnaires (Group 4)	VA Form 21-0960I-3, VA Form 21-0960I-2, VA Form 21-0960N-3, VA Form 21-0960C-11, VA Form 21-0960E-3, VA Form 21-0960N-4, VA Form 21-0960D-1, VA Form 21-0960C-3, VA Form 21-0960H-1, VA Form 21-0960C-7, VA Form 21-0960Q-1, VA Form 21-0960C-6, VA Form 21-0960E-2, VA Form 21-0960L-1, VA Form 21-0960J-4, VA Form 21-0960I-4, VA Form 21-0960I-5	Cranial Nerve Conditions Disability Benefits Questionnaire ,   Narcolepsy Disability Benefits Questionnaire ,   Fibromyalgia Disability Benefits Questionnaire ,   Seizure Disorders (Epilepsy) Disability Benefits Questionnaire ,   Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire ,   Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire ,   Thyroid and Parathyroid Conditions Disability Benefits Questionnaire ,   Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire ,   HIV - Related Illnesses Disability Benefits Questionnaire ,   Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire ,   Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire ,   Nutritional Deficiencies Disability Benefits Questionnaire ,   Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire ,   Respiratory Conditions (Other Than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire ,   Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire ,   Chronic Fatigue Syndrome Disability Benefits Questionnaire ,   Sinusitis/Rhinitis and Other Diseases of the Nose, Throat, Larynx, Pharynx Disability Benefits 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	160,000	160,000	0	0	0	0
Annual Time Burden (Hours)	53,750	56,250	0	0	-2,500	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: The reporting burden has been reduced do to an error in calculations. VA Forms 21-0960-C-3, 21-0960-C-6, 21-0960-C-7, 21-0960-C-11, 21-0960-D-1, 21-0960-E-2, 21-0960-E-3, 21-0960-H-1, 21-0960-I-2, 21-0960-I-3, 21-0960-I-4, 21-0960-I-5, 21-0960-J-4, 21-0960-L-1, 21-0960-N-3, 21-0960-N-4, and 21-0960-Q-1, 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. These forms have also been updated to include an expiration date placeholder.

---

Annual Cost to Federal Government: $6,016,925

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: 01/05/2015

---