Information Collection

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

IC 206614 under ICR 201612-2900-004 · OMB 2900-0802.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0802 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-0960M-1 Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)	Form
VA Form 21-0960M-1 Shoulder and Arm Conditions Disability Benefits Question VBA-21-0960M-12-ARE 3-7-2017.pdf www.va.gov/vaforms	Form

IC Title:

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

Agency IC Tracking Number:

2900-NEW VBA-COMP-DB

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Voluntary

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

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 21-0960M-12	Shoulder and Arm Conditions Disability Benefits Questionnaire	VBA-21-0960M-12-ARE 3-7-2017.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title: Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28)

FR Citation: 75 FR 29275

Number of Respondents: 50,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	25,000	25,000
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.