Information Collection

Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)

IC 28204 under ICR 202404-2900-001 · OMB 2900-0065.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)	Form
Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)	Form
21-4192 Request for Employment Information in Connection with Cl VBA-21-4192-ARE 4-25-24.pdf	Form
21-4192 Request for Employment Information in Connection with Cl VBA-21-4192-ARE 4-25-24.pdf	Form

IC Title:

Agency IC Tracking Number:

2900-0065

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 3.341 38 CFR 3.340 38 CFR 3.342

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	21-4192			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 Veteran Readiness and Employment Records-VA (58VA21/22/28)

FR Citation: 87 FR 8740

Number of Respondents: 48,730

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	48,730	23,480	25,250
Annual IC Time Burden (Hours)	12,183	5,870	6,313
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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