Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 21-0960M-1 Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)	Form	Modified	Available
2017-07865, 30-Day FRN (2900-0802).pdf	Supplementary Document	Uploaded 2017-05-11	Available
2017-01751, 60-Day FRN (2900-0802).pdf	Supplementary Document	Uploaded 2017-02-24	Available
2900-0802, Supporting Statement (21-0960M-12).docx	Supporting Statement A	Uploaded 2017-05-11	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206614	Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)	Form	Modified

ICR Details

OMB Control No: 2900-0802	ICR Reference No: 201612-2900-004
Status: Historical Inactive	Previous ICR Reference No: 201304-2900-029
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-DJ
Title: Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 09/29/2017
	Date Received in OIRA: 05/11/2017
Terms of Clearance: VA withdraws this collection to make a technical correction to the way it was submitted.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved
Responses	50,000	0	0
Time Burden (Hours)	25,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The form will be used to gather necessary information from a claimant's treating physician regarding the results of medical examinations. VA will gather medical information related to the claimant that is necessary to adjudicate the claim for VA disability benefits.

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Authorizing Statute(s): US Code: 38 USC 501(a) Name of Law: Rules and Regulations
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 8568	01/26/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 18537	04/19/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)	VA Form 21-0960M-12	Shoulder and Arm Conditions Disability Benefits Questionnaire

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $4,398,333

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  Yes

Description/Changes for Common Form Usage: 

Approved RCFs using this ICR

table that charts list of RCF

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/11/2017

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