Supporting Statement for
Disability Benefits Questionnaires (DBQ Group 4)
2900-0781
VA Form 21-0960-C-3 |
Cranial Nerve Conditions Disability Benefits Questionnaire |
VA Form 21-0960-C-6 |
Narcolepsy Disability Benefits Questionnaire |
VA Form 21-0960 C-7 |
Fibromyalgia Disability Benefits Questionnaire |
VA Form 21-0960-C-11 |
Seizure Disorders (Epilepsy) Disability Benefits Questionnaire |
VA Form 21-0960-D-1 |
Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire |
VA Form 21-0960-E-2 |
Endocrine Diseases (other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire |
VA Form 21-0960-E-3 |
Thyroid & Parathyroid Conditions Disability Benefits Questionnaire |
VA Form 21-0960-H-1 |
Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire |
VA Form 21-0960-I-2 |
HIV-Related Illnesses Disability Benefits Questionnaire |
VA Form 21-0960-I-3 |
Infectious Diseases (other than HIV-Related Illness, Chronic Fatigue Syndrome, and Tuberculosis) Disability Benefits Questionnaire |
VA Form 21-0960-I-4 |
Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire |
VA Form 21-0960-I-5 |
Nutritional Deficiencies Disability Benefits Questionnaire |
VA Form 21-0960-J-4 |
Urinary Tract ( including Bladder & Urethra) Conditions (excluding Male Reproductive System) Disability Benefits Questionnaire |
VA Form 21-0960-L-1 |
Respiratory Conditions (other than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire |
VA Form 21-0960-N-3 |
Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire |
VA Form 21-0960-N-4 |
Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx, and Pharynx Disability Benefits Questionnaire |
VA Form 21-0960-Q-1 |
Chronic Fatigue Syndrome Disability Benefits Questionnaire |
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. 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. This provision also stipulates that medical evidence such as hospital reports or any examination reports, from any government or private institution may be accepted for rating a claim without further examination. The VA Form 21-0960 series (disability benefits questionnaires) will be used for disability compensation or pension claims which require an examination and/or receiving private medical evidence that may potentially be sufficient for rating purposes. The disability benefits questionnaires (DBQs) will streamline the process by which a Veteran submits relevant medical evidence to VBA for the purpose of rating disabilities in order to provide timely delivery of benefits to our Nation’s Veterans. The straightforward and standardized questions in the DBQs will improve the quality and timeliness of medical evidence necessary to support a Veteran’s claim for disability benefits, which will enable VA to adjudicate claims faster. The DBQs will, in some circumstances, facilitate a Veteran’s application for disability benefits by engaging a treating physician to aid in administering the C&P examination. Use of the streamlined medical questionnaires by private physicians, at the request of Veterans, as well as by VA contractors and VHA physicians, will create an aggregate timeliness advantage for claims processing and thus help alleviate the claims backlog. Leveraging resources of the private medical community will also enable VHA to redirect physician efforts to care and treatment.
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 benefits. The Disability Benefit Questionnaire title will include the name of the specific disability for which it will gather information. VAF 21-0960-C-3, Cranial Nerve Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any cranial nerve condition; VAF 21-0960-C-6, Narcolepsy Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of narcolepsy; VAF 21-0960 C-7, Fibromyalgia Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of fibromyalgia; VAF 21-0960-C-11, Seizure Disorders (Epilepsy) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any seizure disorder including epilepsy; VAF 21-0960-D-1, Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any oral or dental conditions; VAF 21-0960-E-2, Endocrine Diseases (Other Than Thyroid, Parathyroid, or Diabetes Mellitus) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any endocrine disease including cushings and acromegaly however, excluding diabetes; VAF 21-0960-E-3, Thyroid & Parathyroid Conditions Disability Benefits Questionniare, will gather information related to the claimant’s diagnosis of any thyroid or parathyroid condition; VAF 21-0960-H-1, Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of abdominal, inguinal, or femoral hernias; VAF 21-0960-I-2, HIV-Related Illness Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any HIV-related illness; VAF 21-0960-I-3, Infectious Diseases Other Than HIV-Related Illness, Chronic Fatigue Syndrome, and Tuberculosis Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any infectious diseases; VAF 21-0960-I-4, Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of lupus or other immune disorders; VAF 21-0960-I-5, Nutritional Deficiencies Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of nutritional deficiencies; VAF 21-0960-J-4, Urinary Tract ( including Bladder & Urethra) Conditions (excluding Male Reproductive System) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any urinary tract or bladder condition; VAF 21-0960-L-1, Respiratory Conditions (Other than Tuberculosis & Sleep Apnea) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any respiratory condition; VAF 21-0960-N-3, Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire, will gather information related to the claimant’s loss of sense of smell and taste; VAF 21-0960-N-4, Sinusitis/Rhinitis and OtherConditions of the Nose, Throat, Larynx, and Pharynx Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of sinusitis/rhinitis or other diseases of the nose, throat, larynx, or pharynx; VAF 21-0960-Q-1, Chronic Fatigue Syndrome Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of chronic fatigue syndrome.
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 are 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. 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. Once a claim is received, VA has a duty to assist the Veteran in obtaining all necessary evidence to substantiate their claim. Based upon this duty, VA requests all pertinent medical evidence from the Veteran, any Federal Agencies that may have this evidence, any agency or entity which the Veteran has indicated may have this evidence and from which the Veteran has authorized VA to request the information, as well as VA medical evidence. Once evidence has been found to establish an in-service injury or disease, VA will evaluate to determine if there is sufficient current medical evidence to link a current diagnosis to the service-related injury or disease and rate the disability according to current symptomatology by using the rating schedule criteria in 38 CFR Part 4. For internal VA purposes, the DBQs have replaced the current VA examination process in order to obtain the essential medical evidence needed to rate the claim. The forms being used publicly also benefit both the Veteran and VA by providing the necessary relevant medical evidence without the need to request and obtain a VA examination, thus expediting the process for a swift decision. While the potential for duplication of evidence has long existed to some extent with any evidence received, DBQs do not add any new areas of potential duplication; if a DBQ is received then a VA examination will not be required.
The collection of information does not involve small businesses or entities.
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. The provisions of 38 CFR § 3.159 state that in a claim for disability compensation, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record, if VA determines it is necessary to decide the claim. A medical examination or opinion is necessary if there is evidence that the Veteran suffered an event, injury or disease in service, or has a disease or symptoms of a disease listed in § 3.309, 3.313, 3.316, and 3.317, which manifested during an applicable presumptive period, provided the Veteran has the required service or triggering event to qualify for that presumption, and the information and evidence of record does not contain sufficient competent medical evidence to decide the claim. If the Veteran chooses to have his or her private physician complete a DBQ in lieu of a VA examination, the DBQ will solicit the information needed, per rating schedule criteria, to determine the level of disability without the need to schedule a VA medical examination.
There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.
The Department notice was published in the Federal Register on August 28, 2014, Volume 79, No. 167, pages 51399 and 51400. One comment was received in response to this notice.
Comment:
A comment received from Genevieve Gutierrez, QTC-A Lockheed Martin Company proposed changes to each of the DBQs that make up Group IV. 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. Ms. Gutierrez had no other comments on these DBQs under review. Regarding any future substantive changes to these DBQs, VA invites Ms. Gutierrez to submit comments on the content of the form at the time of publication.
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 Rehabilitation Records—VA (58VA21/22/28),” as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009).
There are no questions of a sensitive nature.
Estimate of Information Collection Burden.
Number of Respondents: 160,000 per year for all forms:
VAF 21-0960-C-3 – 10,000
VAF 21-0960-C-6 – 5,000
VAF 21-0960-C-7 – 5,000
VAF 21-0960-C-11 – 5,000
VAF 21-0960-D-1 – 5,000
VAF 21-0960-E-2 – 10,000
VAF 21-0960-E-3 – 10,000
VAF 21-0960-H-1 – 15,000
VAF 21-0960-I-2 – 5,000
VAF 21-0960-I-3 – 10,000
VAF 21-0960-I-4 – 5,000
VAF 21-0960-I-5 – 5,000
VAF 21-0960-J-4 – 15,000
VAF 21-0960-L-1 – 20,000
VAF 21-0960-N-3 – 5,000
VAF 21-0960-N-4 – 20,000
VAF 21-0960-Q-1 – 10,000
Frequency of Response is on occasion for most beneficiaries.
Annual burden hours: 53,750 hours:
VAF 21-0960-C-3 – 5,000
VAF 21-0960-C-6 – 1,250
VAF 21-0960-C-7 – 1,250
VAF 21-0960-C-11 – 1,250
VAF 21-0960-D-1 – 1,250
VAF 21-0960-E-2 – 2,500
VAF 21-0960-E-3 – 2,500
VAF 21-0960-H-1 – 3,750
VAF 21-0960-I -2 – 1,250
VAF 21-0960-I-3 – 2,500
VAF 21-0960-I-4 – 2,500
VAF 21-0960-I-5 – 1,250
VAF 21-0960-J-4 – 3,750
VAF 21-0960-L-1 – 10,000
VAF 21-0960-N-3 – 1,250
VAF 21-0960-N-4 – 10,000
VAF 21-0960-Q-1 – 2,500
Estimated completion time for each form is as follows:
VAF 21-0960-C-3 – 30 minutes
VAF 21-0960-C-6 – 15 minutes
VAF 21-0960-C-7 – 15 minutes
VAF 21-0960-C-11 – 15 minutes
VAF 21-0960-D-1 – 15 minutes
VAF 21-0960-E-2 – 15 minutes
VAF 21-0960-E-3 – 15 minutes
VAF 21-0960-H-1 – 15 minutes
VAF 21-0960-I -2 – 15 minutes
VAF 21-0960-I-3 – 15 minutes
VAF 21-0960-I-4 – 30 minutes
VAF 21-0960-I-5 – 15 minutes
VAF 21-0960-J-4 – 15 minutes
VAF 21-0960-L-1 – 30 minutes
VAF 21-0960-N-3 – 15 minutes
VAF 21-0960-N-4 – 30 minutes
VAF 21-0960-Q-1 – 15 minutes
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 $1,290,000 (53,750 burden hours x $24 per hour).
This submission does not involve any recordkeeping costs.
Estimated Costs to the Federal Government:
Processing/Analyzing costs $6,007,924.50
VAF 21-0960-C-3
(GS-13/5 @ $48.35 x 10,000 x 30/60 minutes = $241,750.00) (GS-12/5 @ $40.66 x 10,000 x 30/60 minutes = $203,300.00)
(GS- 9/5 @ $28.04 x 10,000 x 30/60 minutes = $140,200.00)
Total: $585,250.00
VAF 21-0960-C-6
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS- 9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960-C-7
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS- 9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960-C-11
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS- 9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960-D-1
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS- 9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960-E-2
(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875.00)
(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650.00)
(GS- 9/5 @ $28.04 x 10,000 x 15/60 minutes = $ 70,100.00)
Total: $292,625.00
VAF 21-0960-E-3
(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875.00)
(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650.00)
(GS- 9/5 @ $28.04 x 10,000 x 15/60 minutes = $ 70,100.00)
Total: $292,625.00
VAF 21-0960-H-1
(GS-13/5 @ $48.35 x 15,000 x 15/60 minutes = $181,312)
(GS-12/5 @ $40.66 x 15,000 x 15/60 minutes = $152,475)
(GS- 9/5 @ $28.04 x 15,000 x 15/60 minutes = $105,150)
Total: $438,937.00
VAF 21-0960-I -2
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS- 9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960-I-3
(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875.00)
(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650.00)
(GS- 9/5 @ $28.04 x 10,000 x 15/60 minutes = $ 70,100.00)
Total: $292,625.00
VAF 21-0960-I-4
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS- 9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960-I-5
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS- 9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960-J-4
(GS-13/5 @ $48.35 x 15,000 x 15/60 minutes = $181,312.50)
(GS-12/5 @ $40.66 x 15,000 x 15/60 minutes = $152,475.00)
(GS- 9/5 @ $28.04 x 15,000 x 15/60 minutes = $105,150.00)
Total: $301,737.50
VAF 21-0960-L-1
(GS-13/5 @ $48.35 x 20,000 x 30/60 minutes = $483,500.00)
(GS-12/5 @ $40.66 x 20,000 x 30/60 minutes = $406,600.00)
(GS- 9/5 @ $28.04 x 20,000 x 30/60 minutes = $280,400.00)
Total: $1,170,500.00
VAF 21-0960-N-3
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS- 9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960-N-4
(GS-13/5 @ $48.35 x 20,000 x 30/60 minutes = $483,500.00)
(GS-12/5 @ $40.66 x 20,000 x 30/60 minutes = $406,600.00)
(GS- 9/5 @ $28.04 x 20,000 x 30/60 minutes = $280,400.00)
Total: $1,170,500.00
VAF 21-0960-Q-1
(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875.00)
(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650.00)
(GS- 9/5 @ $28.04 x 10,000 x 15/60 minutes = $ 70,100.00)
Total: $292,625.00
Printing and production cost $9,000
Total cost to government $6,016,924.50
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.
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
This collection of information does not employ statistical methods.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SF 83 SS VAF 21-8926 |
| Author | Veterans Benefits Administrat |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |