Information Collection

Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death (21P-8416b)

IC 28721 under ICR 202402-2900-015 · OMB 2900-0545.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 21P-8416b Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death (21P-8416b)	Form
Form 21P-8416b Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death Report of Medical, Legal, and Other Expenses Incident to Recovery for Injury or Death (21P-8416b)	Form
21P-8416b Report of Medical, Legal, and Other Expenses Incident to VA Form 21P-8416b -New Burden Statement (508 Conformant 6-20-23) 3-28-24.pdf	Form
21P-8416b Report of Medical, Legal, and Other Expenses Incident to VA Form 21P-8416b -New Burden Statement (508 Conformant 6-20-23) 3-28-24.pdf	Form

IC Title:

Agency IC Tracking Number:

2900-0545

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.262 38 CFR 3.272 38 CFR 3.271

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	21P-8416b			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 38

Number of Respondents: 100

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	100	-1,400	1,500
Annual IC Time Burden (Hours)	75	-1,050	1,125
Annual IC Cost Burden (Dollars)	2,232	-26,703	28,935

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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