View Information Collection (IC)

View Information Collection (IC)

IC Title:	Request for Employment Information in Connection with Claim for Disability Benefits	Agency IC Tracking Number:	2900-0065

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-4192	Request for Employment Information in Connection with Claim for Disability Benefits	VA Form 21-4192.pdf	http://www.va.gov/vaforms/	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	60,000	0	0	0	0	60,000
Annual IC Time Burden (Hours)	15,000	0	0	0	0	15,000
Annual IC Cost Burden (Dollars)	0	0	0	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.