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Disability Benefits Questionnaires
Disability Benefits Questionnaires (21-0960A-1, 21-0960B-1, 21-0960C-1)
OMB: 2900-0749
IC ID: 193056
OMB.report
VA
OMB 2900-0749
ICR 201610-2900-005
IC 193056
( )
Documents and Forms
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
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Disability Benefits Questionnaires
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:
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
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:
62,000
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
62,000
0
0
0
0
62,000
Annual IC Time Burden (Hours)
15,500
0
0
0
0
15,500
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.
