Information Collection

Disability Benefits Questionnaires (Group 2)

IC 195946 under ICR 201711-2900-012 · OMB 2900-0776.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-0960A-2 Disability Benefits Questionnaires (Group 2)	Form
VA Form 21-0960A-2 Artery and Vein Conditions (Vascular Diseases including 21-0960A-2.pdf www.va.gov/vaforms	Form
VA Form 21-0960F-1 Scars/Disfigurement Disability Benefits Questionnaire 21-0960F-1.pdf www.va.gov/vaforms	Form
VA Form 21-0960M-1 Temporomandibular Joint (TMJ) Conditions Disability Bene 21-0960M-15.pdf www.va.gov/vaforms	Form
VA Form 21-0960A-4 Heart Conditions (Including Ischemic and Non-Ischemic He 21-0960A-4.pdf www.va.gov/vaforms	Form
VA Form 21-0960C-4 Diabetic Sensory-Motor Peripheral Neuropathy Disability 21-0960C-4.pdf www.va.gov/vaforms	Form
VA Form 21-0960N-2 Eye Conditions Disability Benefits Questionnaire 21-0960N-2.pdf www.va.gov/vaforms	Form
VA Form 21-0960A-3 Hypertension Disability Benefits Questionnaire 21-0960A-3.pdf www.va.gov/vaforms	Form
VA Form 21-0960M-1 Amputations Disability Benefits Questionnaire 21-0960M-1.pdf www.va.gov/vaforms	Form
VA Form 21-0960F-2 Skin Diseases Disability Benefits Questionnaire 21-0960F-2.pdf www.va.gov/vaforms	Form
VA Form 21-0960M-1 Muscle Injuries Disability Benefits Questionnaire 21-0960M-10.pdf www.va.gov/vaforms	Form
VA Form 21-0960E-1 Diabetes Mellitus Disability Benefits Questionnaire 21-0960E-1.pdf www.va.gov/vaforms	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Disability Benefits Questionnaires (Group 2)

Agency IC Tracking Number:

2900-0776 VBA-COMP-DB

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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 21-0960A-2	Artery and Vein Conditions (Vascular Diseases including Varicose Veins) Disability Benefits Questionnaire	21-0960A-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960F-1	Scars/Disfigurement Disability Benefits Questionnaire	21-0960F-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-15	Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire	21-0960M-15.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960A-4	Heart Conditions (Including Ischemic and Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) Disability Benefits Questionnaire	21-0960A-4.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-4	Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire	21-0960C-4.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960N-2	Eye Conditions Disability Benefits Questionnaire	21-0960N-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960A-3	Hypertension Disability Benefits Questionnaire	21-0960A-3.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-1	Amputations Disability Benefits Questionnaire	21-0960M-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960F-2	Skin Diseases Disability Benefits Questionnaire	21-0960F-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-10	Muscle Injuries Disability Benefits Questionnaire	21-0960M-10.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960E-1	Diabetes Mellitus Disability Benefits Questionnaire	21-0960E-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

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 22187

Number of Respondents: 400,000

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	400,000	400,000
Annual IC Time Burden (Hours)	162,500	162,500
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.