OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Disability Benefits Questionnaires (Group 4)

IC 196008 under ICR 201903-2900-012 · OMB 2900-0781.

Documents and Forms

Documents and forms in this information collection
Document NameDocument 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

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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 21-0960C-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


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 160,000 0 0 0 0 160,000
Annual IC Time Burden (Hours) 53,750 0 0 0 0 53,750
Annual IC Cost Burden (Dollars) 0 0 0 0 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.