2900-0826, Supporting Stmt (VAF 21-0966)

Supporting Statement for VA Form 21-0966,

Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC

OMB #2900-0826

1. JUSTIFICATION:

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

The Department of Veterans Affairs (VA), through its Veterans Benefits Administration (VBA), administers an integrated program of benefits and services, established by law, for veterans, service personnel, and their dependents and/or beneficiaries. Title 38 U.S.C. 5102 provides that a specific claim in the form provided by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by the Secretary. The amended collection of information in the final rule 38 CFR 3.155 would require claimants and/or their authorized representatives to submit a VA-prescribed form in either paper or electronic submission, where applicable, to express a claimant’s intent to file a claim for benefits in order to establish an effective date placeholder for any award granted if the claimant files a complete claim within 1 year of receipt of the intent to file a claim. The collection of information has been consolidated into VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension Benefits, or Survivors Pension and/or DIC. Claimants and their representatives can submit their intent to file a claim in three ways: (1) on paper using VA Form 21-0966; (2) electronically through a claims submission tool within a VA Web-based electronic claims application system; or, (3) by telephone contact with VA personnel who will record the intent to file a claim on VA Form 21-0966.

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

VA Form 21-0966 is used by claimants and/or their authorized representatives to indicate intent to file a claim for compensation and/or disability benefits to establish an effective date for an award granted in association with a complete claim filed within 1 year of such form. VA uses this form to identify claimants in its internal business operational systems to record the date of receipt of this document for the purposes of establishing a date of claim for a complete claim that is filed within 1 year. VA also uses the information to furnish the claimant with the appropriate VA form or application for VA benefits.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

VA Form 21-0966 is available on the One-VA Website in a fillable electronic format. VBA is currently hosting this form on a secure server and does not currently have the technology in place to allow for the complete submission of the form. Validation edits are performed to assure data integrity. There currently is no utility process in place that will allow the data submitted on the form to be incorporated with an existing centralized legacy database.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency which maintains the necessary information, nor is it available from other sources within our Department.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The collection of information does not involve small businesses or entities.

6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

VA Form 21-0966 is used to gather the necessary information to determine an effective date for an award granted in association with a complete claim filed within 1 year of such form. VA also uses it as a request for application and responds by mailing the claimant a letter of receipt, along with the appropriate VA form or application for VA benefits. Without this information, determination of entitlement would not be possible.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.

8. If applicable, provide a copy and identify the date and page number of publication in

the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The Department notice was published in the Federal Register on February 12, 2018, Volume 83, No. 29, page 6100. One comment was received in response to this notice.

Comment #1:

VBA received a comment from Patricia Servaes, stating; The form is not clear enough for the one-time user to understand that 1) if the veteran checks compensation but they are filing for pension or vis versa, that they have not established an effective date for the other. 2) that if a surviving spouse checks pension in the veteran area that she has invalidated the form. I think the form should be changed to state that "This is an Intent to File for either a Service Connected Disability Claim or a Pension Claim. If you do not know which you are filing for, check both boxes." Or "This is an Intent to File for either a Service Connected Disability Claim or a Pension Claim." and do not have the claimant check anything. The confusion on the form only results in claimants losing out on benefits, I do not see how there could be any other possible positive result to the claimant by making them select either compensation or Pension at the Intent to File point. They would have a better handle on it by the time they file the full application.

Response #1:

Upon review of Comment #1 above, VA appreciates Ms. Servaes’ comment. However, we believe the instructional notes contained in the referenced area clearly inform the applicant why it is important to complete the section and how to complete it. Therefore, no changes will be made.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payments or gifts to respondents have been made under this collection of information.

10. Describe any assurance of privacy to the extent permitted by law provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

The records are maintained in the appropriate Privacy Act System of Records identified as “Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28),” published at 74 FR 29275 on June 19, 2009, and last amended at 77 FR 42593 (July 19, 2012).

11. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature.

12. Estimate of the hour burden of the collection of information:

1. Number of Respondents is estimated at 724,561 per year.

2. Frequency of Response is one time.

3. Annual burden hours are 181,140 hours.

4. The estimated completion time for each form is 15 minutes.

5. The respondent population for VA Form 21-0966 is composed of individuals who are applying for benefits to establish an effective date. VA cannot make further assumptions about the population of respondents because of the variability of factors such as the educational background and wage potential of respondents.  Therefore, VBA used general wage data to estimate the respondents’ costs associated with completing the information collection.

The Bureau of Labor Statistics (BLS) gathers information on full-time wage and salary workers.  According to the latest available BLS data, the mean weekly earnings of full-time wage and salary workers are $973.60.  Assuming a forty (40) hour work week, the mean hourly wage is $24.34 based on the BLS wage code – “00-0000 All Occupations.”  This information was taken from the following website:

(https://www.bls.gov/oes/current/oes_nat.htm, May 2017). 

Legally, respondents may not pay a person or business for assistance in completing the information collection. Therefore, there are no expected overhead costs for completing the information collection. VBA estimates the total cost to all respondents to be $4,408,947.60 (181,140 burden hours x $24.34 per hour).

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

This submission does not involve any recordkeeping costs.

14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

Estimated Costs to the Federal Government:

Grade	Step	Burden Time	Fraction of Hour	Hourly Rate	Cost Per Response	Total Responses	Total
5	3	15	0.25	$14.79	3.698	724,561	$ 2,679,064.30
Overhead at 100% Salary							$ 2,679,064.30
7	3	15	0.25	$18.32	4.580	724,561	$ 3,318,489.38
Overhead at 100% Salary							$ 3,318,489.38
9	3	5	0.08	$22.42	1.868	724,561	$ 1,353,721.47
Overhead at 100% Salary							$ 1,353,721.47
Processing / Analyzing Costs							$ 14,702,550.29
Printing and Production Cost							$ 163,361.67
Total Cost to Government							$ 14,865,911.96

Overhead costs are 100% of salary and are same as the wage listed above and the amounts are included in the total.

Note: The hourly wage information above is based on the hourly 2018 General Schedule (Base) Pay (https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2018/GS_h.pdf). This rate does not include any locality adjustment as applicable.

The processing time estimates above are based on the actual amount of time employees of each grade level spend to process to completion a claim received on this form. The within-grade step (3) of each employee represents the average experience of employees within each grade.

15. Explain the reason for any burden hour changes since the last submission.

There is no change in the respondent burden.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

The information collection is not for publication or tabulation use.

17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

We are not seeking approval to omit the expiration date for OMB approval.

18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

This submission does not contain any exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

No statistical methods are used in this data collection.