Information Collection

Disability Benefits Questionnaires

IC 193056 under ICR 201610-2900-005 · OMB 2900-0749.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-0960A-1 Disability Benefits Questionnaires	Form
VA Form 21-0960A-1 Ischemic Heart Disease (IHD) Disability Benefits Questio 21-0960A-1.pdf www.va,gov/vaforms	Form
VA Form 21-0960B-1 Hairy Cell and Other B-Cell Leukemias Disability Benefit VBA-21-0960B-1-ARE 11-02-2016.pdf www.va.gov/vaforms	Form
VA Form 21-0960C-1 Parkinson's Disease Disability Benefits Questionnaire VBA-21-0960C-1-ARE 11-02-2016.pdf www.va.gov/vaforms	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.326 38 CFR 3.351d 38 CFR 3.351e

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-0960A-1	Ischemic Heart Disease (IHD) Disability Benefits Questionnaire	21-0960A-1.pdf	www.va,gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960B-1	Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire	VBA-21-0960B-1-ARE 11-02-2016.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-1	Parkinson's Disease Disability Benefits Questionnaire	VBA-21-0960C-1-ARE 11-02-2016.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 62,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	62,000	62,000
Annual IC Time Burden (Hours)	15,500	15,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.