Document Name Document Type
Form VA Form 21-0960C-3 Disability Benefits Questionnaires (Group 4) Form
VA Form 21-0960C-3 Cranial Nerves Diseases Disability Benefits Questionnair VBA-21-0960C-3-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960C-6 Narcolepsy Disability Benefits Questionnaire VBA-21-0960C-6-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960C-7 Fibromyalgia Disability Benefits Questionnaire VBA-21-0960C-7-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960C-1 Seizure Disorders (Epilepsy) Disability Benefits Questio VBA-21-0960C-11-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960D-1 Oral and Dental Conditions Including Mouth, Lips and Ton VBA-21-0960D-1-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960E-2 Endocrine Diseases (Other than Thyroid, Parathyroid or D VBA-21-0960E-2-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960E-3 Thyroid and Parathyroid Conditions VBA-21-0960E-3-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960H-1 Hernias (Including Abdominal, Inguinal and Femoral Herni VBA-21-0960H-1-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960I-2 HIV-Related Illnesses Disability Benefits Questionnaire VBA-21-0960I-2-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960I-3 Infectious Diseases (Other than HIV-Related Illness, Chr VBA-21-0960I-3-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960I-4 Systemic Lupus Erythematosus (SLE) and Other Autoimmune VBA-21-0960I-4-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960I-5 Nutritional Deficiencies Disability Benefits Questionnai VBA-21-0960I-5-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960J-4 Urinary Tract (Including Bladder and Urethra Conditions) VBA-21-0960J-4-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960L-1 Respiratory Conditions (Other than Tuberculosis and Slee VBA-21-0960L-1-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960N-3 Loss of Sense of Smell and/or Taste Disability Benefits VBA-21-0960N-3-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960N-4 Sinusitis/Rhinitis and Other Conditions of the Nose, Thr VBA-21-0960N-4-ARE.pdf www.va.gov/vaforms Form
VA Form 21-0960Q-1 Chronic Fatigue Syndrome Disability Benefits Questionnai VBA-21-0960Q-1-ARE.pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Disability Benefits Questionnaires (Group 4)	Agency IC Tracking Number:	2900-0781

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-0960C-3	Cranial Nerves Diseases Disability Benefits Questionnaire	VBA-21-0960C-3-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-6	Narcolepsy Disability Benefits Questionnaire	VBA-21-0960C-6-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-7	Fibromyalgia Disability Benefits Questionnaire	VBA-21-0960C-7-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-11	Seizure Disorders (Epilepsy) Disability Benefits Questionnaire	VBA-21-0960C-11-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960H-1	Hernias (Including Abdominal, Inguinal and Femoral Hernias) Disability Benefits Questionnaire	VBA-21-0960H-1-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-2	HIV-Related Illnesses Disability Benefits Questionnaire	VBA-21-0960I-2-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-3	Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire	VBA-21-0960I-3-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-4	Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire	VBA-21-0960I-4-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-5	Nutritional Deficiencies Disability Benefits Questionnaire	VBA-21-0960I-5-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960D-1	Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire	VBA-21-0960D-1-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960E-2	Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire	VBA-21-0960E-2-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960E-3	Thyroid and Parathyroid Conditions	VBA-21-0960E-3-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960J-4	Urinary Tract (Including Bladder and Urethra Conditions) (Excluding Male Reproductive System Disability Benefits Questionnaire	VBA-21-0960J-4-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960L-1	Respiratory Conditions (Other than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire	VBA-21-0960L-1-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960N-3	Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire	VBA-21-0960N-3-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960N-4	Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire	VBA-21-0960N-4-ARE.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960Q-1	Chronic Fatigue Syndrome Disability Benefits Questionnaire	VBA-21-0960Q-1-ARE.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:	FR Citation:

Number of Respondents: 160,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	160,000	160,000
Annual IC Time Burden (Hours)	53,750	53,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.

Disability Benefits Questionnaires (Group 4)

Disability Benefits Questionnaires (Group 4)

OMB: 2900-0781

IC ID: 196008

View Information Collection (IC)