2900-0001 -SuppStmt (7-29-14)

Supporting Statement for:

(2900-0001)

VA Form 21-526	Veteran’s Application for Compensation and/or Pension
VA Form 21-526b	Veteran’s Supplemental Claim Application
VA Form 21-4142a	General Release for Medical Provider Information to the Department of Veterans Affairs (VA)
VA Form 21-4142	Authorization and Consent to Release Information to the Department of Veterans Affairs

A. Justification

1. 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. VA Form 21-526 is the prescribed form for initial disability claims. VA Form 21-526b is the prescribed form for supplemental disability or ancillary benefit claims. VA Form 21-4142 is used to authorize the disclosure of information to the VA and VA Form 21-4142a is used to gather private provider information of the Veteran to VA.

The Final Rule RIN 2900-AO81, Standard Claims and Appeals Forms, which requires all claims for benefits to be submitted on an application or form prescribed by the Secretary. VA is codifying its regulations to standardize the use of all VA forms, to include VA Forms 21-526 and 21-526b.

2. VA Form 21-526 and 21-526b are used to gather the necessary information to determine a veteran’s eligibility, dependency, and income, as applicable, for the compensation and/or pension benefit sought. Without this information, determination of entitlement would not be possible. In order to expedite and streamline the claims adjudication process, VA codifies the requirement that claimants submit these forms to claim compensation and/or pension benefits on VA Form 21-526 or supplemental benefits on VA Form 21-526b in its adjudication regulations.

3. VA Forms 21-4142, 21-4142a, 21-526, and 21-526b is 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. 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.

4. 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.

5. The collection of information does not involve small businesses or entities.

6. These forms were redesigned into a “user friendly” form, incorporating plain English, to comply with the President’s Memorandum of June 1, 1998, Plain Language in Government Writing.

7. There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.

8. The Department notice was published in proposed rule, RIN 2900-AO81, Standard Claims and Appeals Forms, on October 31, 2013, Vol. 78, No. 211, pages 65490-65509. No comments were received.

9. No payments or gifts to respondents have been made under this collection of information.

10. 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).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

1. Number of yearly respondents totals = 433,433:

   1. 83,855 for VA Form 21-526,

   2. 217,178 for VA Form 21-526b

   3. 66,200 for VA Form 21-4142, and

   4. 66,200 for VA Form 21-4142a.

2. Frequency of Response is one time.

3. Annual burden total = 149,182:

   1. 83,855 for VA Form 21-526,

   2. 54,295 for VA Form 21-526b,

   3. 5,516 for VA Form 21-4142, and

   4. 5,516 for VA Form 21-4142a.

4. The estimated completion time is:

   1. 60 minutes for VA Form 21-526,

   2. 15 minutes for VA Form 21-526b,

   3. 5 minutes for VA Form 21-4142, and

   4. 5 minutes for VA Form 21-4142a.

5. 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 $3,580,368 (149,182 burden hours x $24 per hour).

13. VA recognizes there may be costs with 3^rd party assistance. VA requests input from the public.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $4,183,085

• (GS- 9/5 @ $28.04 x 83,855 x 60/60 minutes = $2,351,294)

• (GS- 9/5 @ $28.04 x 217,178 x 15/60 minutes = $1,522,417)

• (GS- 9/5 @ $28.04 x 66,200 x 5/60 minutes = $154,687)

• (GS- 9/5 @ $28.04 x 66,200 x 5/60 minutes = $154,687)

b. Forms are available on the VA inter/intranet forms websites.

c. Printing and production cost ($90/thousand) $5,490

d. Total cost to government $4,188,575

15. The decrease in burden is due to the Final Rule RIN 2900-AO81, Standard Claims and Appeals Forms which requires all claims for benefits to be submitted on an application or form prescribed by the Secretary. VA is codifying its regulations to standardize the use of all VA forms, to include VA Forms 21-526 and 21-526b. Currently, other than for the initial original claim, VA does not require that claimants submit any subsequent claim on a prescribed VA form. Although there is no substantive change in these forms, VA expects a change in the number of respondents submitting VA Forms 21-526 and 21-526b on account of VA’s electronic claims processing system which uses another form, i.e., VA Form 21-526EZ, that contains the 38 U.S.C. 5103 notices to claimants and that essentially combines the existing VA Form 21-526 and VA Form 21-526b together. The total estimated costs to respondents and the federal government have changed as shown in paragraphs 12 and 14 of this statement.

16. We are not seeking approval to omit the expiration date for OMB approval.

17. The information collection is not for publication or tabulation use.

18. 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.