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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
2900-0776
ICR Reference No:
201201-2900-003
Status:
Historical Active
Previous ICR Reference No:
201112-2900-014
Agency/Subagency:
VA
Agency Tracking No:
2900-0776
Title:
Disability Benefits Questionnaires (Group 2)
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
01/23/2012
Retrieve Notice of Action (NOA)
Date Received in OIRA:
01/12/2012
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
09/30/2014
09/30/2014
09/30/2014
Responses
725,000
0
725,000
Time Burden (Hours)
311,250
0
311,250
Cost Burden (Dollars)
0
0
0
Abstract:
These forms are being created to assist veterans who require a disability examination in support of a claim for VA benefits. These forms will be used to record the findings of the examining physician.
Authorizing Statute(s):
US Code:
38 USC 501(a)
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
76 FR 56
03/23/2011
30-day Notice:
Federal Register Citation:
Citation Date:
76 FR 110
06/08/2011
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Disability Benefits Questionnaires (Group 2)
VA Form 21-0960M-10, VA Form 21-0960C-4, VA Form 21-0960M-4, VA Form 21-0960M-15, VA Form 21-0960M-9, VA Form 21-0960F-1, VA Form 21-0960M-2, VA Form 21-0960M-16, VA Form 21-0960A-2, VA Form 21-0960M-12, VA Form 21-0960M-6, VA Form 21-0960A-4, VA Form 21-0960N-2, VA Form 21-0960M-7, VA Form 21-0960M-5, VA Form 21-0960M-8, VA Form 21-0960E-1, VA Form 21-0960F-2, VA Form 21-0960M-1, VA Form 21-0960A-3
Foot Miscellaneous (Other than Flatfoot/Pes Planus) Disability Benefits Questionnaire
,
Ankle Conditons Disability Benefits Questionnaire
,
Shoulder and Arm Conditions Disability Benefits Questionnaire
,
Artery and Vein Conditions (Vascular Diseases including Varicose Veins) Disability Benefits Questionnaire
,
Flatfoot (Pes Planus) Disability Benefits Questionnaire
,
Scars/Disfigurement Disability Benefits Questionnaire
,
Wrist Conditions Disability Benefits Questionnaire
,
Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire
,
Hand and Finger Conditions Disability Benefits Questionnaire
,
Hip and Thigh Conditions Disability Benefits Questionnaire
,
Knee and Lower Leg Conditions Disability Benefits Questionnaire
,
Heart Conditions (Including Ischemic and Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) Disability Benefits Questionnaire
,
Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire
,
Elbow and Forearm Conditions Disability Benefits Questionnaire
,
Eye Conditions Disability Benefits Questionnaire
,
Hypertension Disability Benefits Questionnaire
,
Amputations Disability Benefits Questionnaire
,
Skin Diseases Disability Benefits Questionnaire
,
Muscle Injuries Disability Benefits Questionnaire
,
Diabetes Mellitus Disability Benefits Questionnaire
ICR Summary 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
725,000
725,000
0
0
0
0
Annual Time Burden (Hours)
311,250
311,250
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$724,255,875
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
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?
Uncollected
Agency Contact:
Denise McLamb 202-565-8374 denise.mclamb@mail.va.gov
Common Form ICR:
No
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:
01/12/2012
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