Elbow and Forearm Conditions Disability Benefits Questionnaire (21-0960M-4)

Forms and Documents

Document Name	Status
Form 21-0960M-4 Elbow and Forearm Conditions Disability Benefits Questionnaire (21-0960M-4) Form	Modified
2017-04426.pdf Supplementary Document	2017-03-22
2016-31317, 60-Day FRN (2900-0812).pdf Supplementary Document	2017-02-24
2900-0812, Supporting Statement (21-0960M-4).doc Supporting Statement A	2017-02-24

IC Document Collections

IC ID	Document Title	Status
206556	Elbow and Forearm Conditions Disability Benefits Questionnaire (21-0960M-4) Form	Modified

ICR Details

OMB Control No: 2900-0812	ICR Reference No: 201612-2900-012
Status: Historical Active	Previous ICR Reference No: 201304-2900-011
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Elbow and Forearm Conditions Disability Benefits Questionnaire (21-0960M-4)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/16/2017
	Date Received in OIRA: 03/22/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved	06/30/2017
Responses	20,000	0	20,000
Time Burden (Hours)	10,000	0	10,000
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:
	81 FR 95734	12/28/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 4426	03/07/2017
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Elbow and Forearm Conditions Disability Benefits Questionnaire (21-0960M-4)	21-0960M-4	Elbow and Forearm Conditions Disability Benefits Questionnaire

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	20,000	20,000	0	0	0	0
Annual Time Burden (Hours)	10,000	10,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: $1,741,740

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:  No

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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: 03/22/2017

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