Information Collection

Employment Questionnaire (21-4140 & 21-4140-1)

IC 28229 under ICR 201702-2900-003 · OMB 2900-0079.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0079 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 21-4140 Employment Questionnaire (21-4140 & 21-4140-1)	Form
21-4140 Employment Questionnaire VBA-21-4140-ARE 6-2-2017.pdf Xerox at Hines	Form
21-4140-1 Employment Questionnaire VBA-21-4140-1-ARE 6-2-2017.pdf www.va.gov/vaforms	Form

IC Title:

Employment Questionnaire (21-4140 & 21-4140-1)

Agency IC Tracking Number:

2900-0079 VBA-COMP-YM

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.343 38 CFR 3.901 38 CFR 4.16 38 CFR 3.362

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	21-4140	Employment Questionnaire	VBA-21-4140-ARE 6-2-2017.pdf	Xerox at Hines	No		Paper Only
Form	21-4140-1	Employment Questionnaire	VBA-21-4140-1-ARE 6-2-2017.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: 130,000

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	130,000	130,000
Annual IC Time Burden (Hours)	10,833	10,833
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.