View Information Collection Request (ICR) Package
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View Information Collection (IC) List
View Supporting Statement and Other Documents
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:
2900-0826
ICR Reference No:
201407-2900-019
Status:
Historical Active
Previous ICR Reference No:
Agency/Subagency:
VA
Agency Tracking No:
2900-NEW - COMP-NK
Title:
Intent to File a Claim for Compensation and/or Pension, Survivors Pension, or Other Benefits (VA Form 21-0966)
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
No
Type of Review Request:
Emergency
Approval Requested By:
04/17/2014
OIRA Conclusion Action:
Approved with change
Conclusion Date:
11/19/2014
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/30/2014
Terms of Clearance:
VA shall seek public comment and submit an extension of this collection within six months if it wishes to continue to collect this information.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/2015
6 Months From Approved
Responses
724,561
0
0
Time Burden (Hours)
181,140
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
VA Form 21-0966 will be used by claimants and/or their authorized representatives to indicate an intent to file a claim for compensation and/or disability benefits to establish an effective date for an award granted in association with a complete claim filed within 1 year of such form.
Emergency Justfication:
Resubmited due to form revision.
Authorizing Statute(s):
US Code:
38 USC 5102
Name of Law: Application forms furnished upon request; notice to claimants of incomplete applications
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
2900-AO81
Final or interim final rulemaking
79 FR 57660
09/25/2014
Federal Register Notices & Comments
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
INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION, SURVIVORS PENSION, OR OTHER BENEFITS
VA Form 21-0966
Intent to File a Claim for Compensation or Pension, Survivors Pension, or Other Benefits
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
724,561
0
0
724,561
0
0
Annual Time Burden (Hours)
181,140
0
0
181,140
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
The respondent burden increases because VA Form 21-0966 is a new form and will be used by claimants and/or their authorized representatives to indicate an intent to file a claim for compensation and/or disability benefits to establish an effective date for an award granted in association with a complete claim filed within 1 year of such form.
Annual Cost to Federal Government:
$5,135,607
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:
Crystal Rennie 202 632-7492 crystal.rennie@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:
07/30/2014
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