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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 21-0960M-12 Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)	Form	Modified	Available
2017-07865, 30-Day FRN (2900-0802).pdf	Supplementary Document	Uploaded 2017-09-28	Repair queued
2017-01751, 60-Day FRN (2900-0802).pdf	Supplementary Document	Uploaded 2017-09-28	Available
2900-0802, Supporting Statement (21-0960M-12).docx	Supporting Statement A	Uploaded 2017-09-28	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: 201709-2900-021
Status: Historical Active	Previous ICR Reference No: 201304-2900-029
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-DJ
Title: Shoulder and Arm Conditions Disability Benefits Questionnaire (VA Form 21-0960M-12)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/13/2017
	Date Received in OIRA: 09/29/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2020	36 Months From Approved
Responses	50,000	0	0
Time Burden (Hours)	25,000	0	0
Cost Burden (Dollars)	0	0	0

---

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. VA Form 21-0960M-12 is being revised to include new standardization data points; to include optical character recognition boxes. This is a non-substantive change.

---

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

Citations for New Statutory Requirements: None

---

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

---

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

---

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

---

ICR Summary of Burden

table that charts list 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	50,000	0	0	0	0	50,000
Annual Time Burden (Hours)	25,000	0	0	0	0	25,000
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:

---

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

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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

---

Common Form ICR:  No

---

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: 09/29/2017

---