Statement in Support of Claim for Service Connection for PTSD (VA Form 21-0781), Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault (VA Form 21-0781a)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 21-0781a Statement in Support of Claim for Service Connection for Post Traumatic Stress Disorder Secondary to Personal Assault	Form	Modified	Available
Form 21-0781 Statement in Support of Claim for Service Connection for Post Traumatic Stress Disorder (PTSD)	Form	Modified	Available
Form 21-0781 Statement in Support of Claim for Service Connection for PTSD (VAF21-0781), Statement in Support of Claim for Service Connection for PTSD(VAF 21-0781a)	Form	Modified	Repair queued
2021-03882, 30-Day FRN (2900-0659).pdf	Supplementary Document	Uploaded 2021-02-25	Repair queued
2020-24647, 60-Day FRN (2900-0659).pdf	Supplementary Document	Uploaded 2020-12-17	Repair queued
2900-0659, Supporting Stmt (VAF21-0781 series).docx	Supporting Statement A	Uploaded 2021-02-19	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28937	Statement in Support of Claim for Service Connection for PTSD (VAF21-0781), Statement in Support of Claim for Service Connection for PTSD(VAF 21-0781a)	Form	Modified	Statement in Support of Claim for Service Connection for Post Traumatic Stress Disorder Secondary to Personal Assault
28937	Statement in Support of Claim for Service Connection for PTSD (VAF21-0781), Statement in Support of Claim for Service Connection for PTSD(VAF 21-0781a)	Form	Modified	Statement in Support of Claim for Service Connection for Post Traumatic Stress Disorder (PTSD)
28937	Statement in Support of Claim for Service Connection for PTSD (VAF21-0781), Statement in Support of Claim for Service Connection for PTSD(VAF 21-0781a)	Form	Modified

ICR Details

OMB Control No: 2900-0659	ICR Reference No: 202009-2900-006
Status: Historical Active	Previous ICR Reference No: 201610-2900-003
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-MS
Title: Statement in Support of Claim for Service Connection for PTSD (VA Form 21-0781), Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault (VA Form 21-0781a)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/02/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/05/2021
Terms of Clearance: In the next revision, extension, or reinstatement request: 1. Please explore whether survivors of sexual assault can use copies of prior descriptions/records, police complaints, etc. in lieu of completing a description of the assault on this form. 2. Modify "Your obligation to respond is voluntary" to "Your response is voluntary."

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2024	36 Months From Approved
Responses	20,374	0	0
Time Burden (Hours)	23,770	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: VA Forms 21-0781 and 21-0781a are used to gather information about stressful incidents in service from veterans claiming compensation for Post-Traumatic Stress Disorder (PTSD). The forms request the information that is necessary for VA to conduct meaningful research of records in order to assist claimants in obtaining credible supporting evidence that the incidents occurred. Without this collection of information, VA would not be able to fulfill its statutory duty to assist for claimants and would be unable to properly authorize benefits. No changes have been made to these forms. The increase in respondent burden is due to the estimated number of receivables from the previous year.

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Authorizing Statute(s): US Code: 38 USC 5101 Name of Law: Claims and Forms
   US Code: 38 USC 5103a Name of Law: Duty to assist claimants
   US Code: 38 USC 5107a Name of Law: Claimant responsibility; benefit of the doubt
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 71139	11/06/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 11593	02/25/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Statement in Support of Claim for Service Connection for PTSD (VAF21-0781), Statement in Support of Claim for Service Connection for PTSD(VAF 21-0781a)	21-0781, 21-0781a	Statement in Support of Claim for Service Connection for Post Traumatic Stress Disorder (PTSD) ,   Statement in Support of Claim for Service Connection for Post Traumatic Stress Disorder Secondary to Personal Assault

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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	20,374	0	0	5,134	0	15,240
Annual Time Burden (Hours)	23,770	0	0	5,990	0	17,780
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The respondent burden has increased due to the estimated number of receivables averaged over the past year.

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Annual Cost to Federal Government: $1,282,991

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? No

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Common Form ICR:  No

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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: 03/05/2021

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