2900-0749 (a-1, B-1, C-1), (2-10-17)

Disability Benefits Questionnaires

OMB 2900-0749

VA Form 21-0960A-1	Ischemic Heart Disease (IHD) Disability Benefits Questionnaire
VA Form 21-0960B-1	Hairy Cell and Other B-cell Leukemias Disability Benefits Questionnaire
VA Form 21-0960C-1	Parkinson's Disease Disability Benefits Questionnaire

1. JUSTIFICATION:

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

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) 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. VA Form 21-0960 series is used for disability compensation or pension claims which require an examination.

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

VA Form 21-0960 series is used to gather necessary information from a claimant’s treating physician regarding the results of medical examinations. VA gathers medical information related to the claimant that is necessary to adjudicate the claim for VA disability benenfits.  The Disability Benefit Questionnaire title will include the name of the specific disability for which it will gather information. VA Form 21-0960A-1, Ischemic Heart Disease (IHD) Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of ischemic heart disease. VA Form 21-0960B-1, Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of Leukemia. VA Form 21-0960C-1, Parkinsons Disease Disability Benefits Questionnaire will gather specific information related to the claimant’s diagnosis of Parkinsons Disease.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

VA Forms 21-0960A-1, 21-0960B-1, and 21-0960C-1, are available on the One-VA web site 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.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

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.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

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

6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

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.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

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

8. A. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The Department notice was published in the Federal Register on November 16, 2016, Volume 81, No. 221, pages 80720 and 80721. No comments were received in response to this notice.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

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

10. Describe any assurance of privacy to the extent permitted by law provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

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 on June 19, 2009, and last amended at 77 FR 42593 (July 19, 2012).

11. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature.

12. Estimate of the hour burden of the collection of information:

1. Number of Respondents is estimated at 62,000 per year.

1. VA Form 21-0960A-1 is 55,000.

2. VA Form 21-0960B-1 is 2,000.

3. VA Form 21-0960C-1 is 5,000.

2. Frequency of Response is once.

3. Annual burden is 15,500 hours.

1. VA Form 21-0960A-1 is 13,750.

2. VA Form 21-0960B-1 is 500.

3. VA Form 21-0960C-1 is 1,250.

4. The estimated completion time is 15 minutes.

5. The respondent population for VA Forms 21-0960A-1, 21-0960B-1, and 21-0960C-1 is composed of individuals gathering the necessary information from a claimant’s treating physician regarding the results of medical examinations. VBA cannot make further assumptions about the population of respondents because of the variability of factors such as the educational background and wage potential of respondents.  Therefore, VBA used general wage data to estimate the respondents’ costs associated with completing the information collection.

The Bureau of Labor Statistics (BLS) gathers information on full-time wage and salary workers. According to the latest available BLS data, the median weekly earnings of full-time wage and salary workers are $929.20. Assuming a forty (40) hour work week, the median hourly wage is $23.23 based on the BLS wage code – “00-0000 All Occupations”. This information is taken from the following website: (http://www.bls.gov/oes/current/oes_nat.htm, May 2015).

Legally, respondents may not pay a person or business for assistance in completing the information collection. Therefore, there are no expected overhead costs for completing the information collection. VBA estimates the total cost to all respondents to be $360,065 (15,500 burden hours x $23.23 per hour).

13. Provide an estimate of the total annual cost burden to respondents or record-keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

This submission does not involve any recordkeeping costs.

13. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

Estimated Costs to the Federal Government:

Grade	Step	Burden Time	Fraction of Hour	Hourly Rate	Cost Per Response	Total Responses	Total
9	3	60	1.00	$21.89	21.890	62,000	$1,357,180.00
Overhead at 100% Salary							$1,357,180.00
11	3	30	0.50	$26.48	13.240	62,000	$ 820,880.00
Overhead at 100% Salary							$ 820,880.00
12	3	15	0.25	$31.74	7.935	62,000	$ 491,970.00
Overhead at 100% Salary							$ 491,970.00
Processing / Analyzing Costs							$5,340,060.00
Printing and Production Cost							$ 59,334.00
Total Cost to Government							$5,399,394.00

Overhead costs are 100% of salary and are same as the wage listed above and the amounts are included in the total.

Note: the hourly wage information above is based on the hourly 2016 General Schedule (Base) Pay (https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/2016/general-schedule/). This rate does not include any locality adjustment as applicable.

The processing time estimates above are based on the actual amount of time employees of each grade level spend to process to completion a claim received on this form. The within-grade step (3) of each employee represents the average experience of employees within each grade.

13. Explain the reason for any burden hour changes since the last submission.

There is no change in the reporting burden.

13. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

The information collection is not for publication or tabulation use.

13. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

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

13. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

This submission does not contain any exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

No statistical methods are used in this data collection.