Information Collection

Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s) (VA Form 21-0781)

IC 28937 under ICR 202311-2900-013 · OMB 2900-0659.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 21-0781 Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s) (VA Form 21-0781)	Form
Form VA Form 21-0781 Statement in Support of Claimed Mental Health Disorder(s) Due to an In Service Traumatic Event(s) Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s) (VA Form 21-0781)	Form
VA Form 21-0781 Statement in Support of Claimed Mental Health Disorder(s 21-0781(2-14-24).pdf	Form
VA Form 21-0781 Statement in Support of Claimed Mental Health Disorder(s 21-0781(3-28-24).pdf	Form

IC Title:

Agency IC Tracking Number:

2900-0659

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 3.304(f)

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 21-0781			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: 89 FR 86220

Number of Respondents: 116,581

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	116,581	96,207	20,374
Annual IC Time Burden (Hours)	87,436	63,666	23,770
Annual IC Cost Burden (Dollars)	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.

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