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Disability Benefits Questionnaires (Group 4)
Disability Benefits Questionnaires (Group 4)
OMB: 2900-0781
IC ID: 196008
OMB.report
VA
OMB 2900-0781
ICR 201511-2900-002
IC 196008
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0781 can be found here:
2019-10-01 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
Form VA Form 21-0960C-3
Disability Benefits Questionnaires (Group 4)
Form
VA Form 21-0960C-3 Cranial Nerves Diseases Disability Benefits Questionnair
21-0960C-3(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960C-6 Narcolepsy Disability Benefits Questionnaire
21-0960C-6(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960C-7 Fibromyalgia Disability Benefits Questionnaire
21-0960C-7(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960C-1 Seizure Disorders (Epilepsy) Disability Benefits Questio
21-0960C-11(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960D-1 Oral and Dental Conditions Including Mouth, Lips and Ton
21-0960D-1(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960E-2 Endocrine Diseases (Other than Thyroid, Parathyroid or D
21-0960E-2(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960E-3 Thyroid and Parathyroid Conditions Disability Benefits Q
21-0960E-3(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960H-1 Hernias (Including Abdominal, Inguinal and Femoral Herni
21-0960H-1(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960I-2 HIV - Related Illnesses Disability Benefits Questionnair
21-0960I-2(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960I-3 Infectious Diseases (Other than HIV-Related Illness, Chr
21-0960I-3(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960I-4 Systemic Lupus Erythematosus (SLE) and Other Autoimmune
21-0960I-4(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960I-5 Nutritional Deficiencies Disability Benefits Questionnai
21-0960I-5(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960J-4 Urinary Tract (Including Bladder and Urethra) Conditions
21-0960J-4(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960L-1 Respiratory Conditions (Other than Tuberculosis and Slee
21-0960L-1(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960N-3 Loss of Sense of Smell and/or Taste Disability Benefits
21-0960N-3(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960N-4 Sinusitis/Rhinitis and Other Conditions of the Nose, Thr
21-0960N-4(1-21-16).pdf
www.va.gov/vaforms
Form
VA Form 21-0960Q-1 Chronic Fatigue Syndrome Disability Benefits Questionnai
21-0960Q-1(1-21-16).pdf
www.va.gov/vaforms
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Disability Benefits Questionnaires (Group 4)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
VA Form 21-0960C-3
Cranial Nerves Diseases Disability Benefits Questionnaire
21-0960C-3(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960C-6
Narcolepsy Disability Benefits Questionnaire
21-0960C-6(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960C-7
Fibromyalgia Disability Benefits Questionnaire
21-0960C-7(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960C-11
Seizure Disorders (Epilepsy) Disability Benefits Questionnaire
21-0960C-11(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960D-1
Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire
21-0960D-1(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960E-2
Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire
21-0960E-2(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960E-3
Thyroid and Parathyroid Conditions Disability Benefits Questionnaire
21-0960E-3(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960H-1
Hernias (Including Abdominal, Inguinal and Femoral Hernias) Disability Benefits Questionnaire
21-0960H-1(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960I-2
HIV - Related Illnesses Disability Benefits Questionnaire
21-0960I-2(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960I-3
Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire
21-0960I-3(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960I-4
Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire
21-0960I-4(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960I-5
Nutritional Deficiencies Disability Benefits Questionnaire
21-0960I-5(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960J-4
Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire
21-0960J-4(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960L-1
Respiratory Conditions (Other than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire
21-0960L-1(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960N-3
Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire
21-0960N-3(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960N-4
Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire
21-0960N-4(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
VA Form 21-0960Q-1
Chronic Fatigue Syndrome Disability Benefits Questionnaire
21-0960Q-1(1-21-16).pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
General Government
Subfunction:
Legislative Functions
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
160,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
160,000
0
0
0
0
160,000
Annual IC Time Burden (Hours)
53,750
0
0
0
0
53,750
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.