Information Collection

Employment Questionnaire (VA Form 21-4140)

IC 28229 under ICR 202009-2900-012 · OMB 2900-0079.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0079 can be found here:

Documents and Forms

Document Name Document Type
Form 21-4140 Employment Questionnaire (VA Form 21-4140) Form
21-4140 Employment Questionnaire VA Form 21-4140 (OMB Exp. 10-31-20).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Employment Questionnaire (VA Form 21-4140)	Agency IC Tracking Number:	2900-0079

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.343 38 CFR 4.16 38 CFR 3.362

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-4140	Employment Questionnaire	VA Form 21-4140 (OMB Exp. 10-31-20).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

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: 84 FR 4138

Number of Respondents: 2,960	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,960	-127,040	130,000
Annual IC Time Burden (Hours)	247	-10,586	10,833
Annual IC Cost Burden (Dollars)	0	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.