View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 2900-0659	ICR Reference No: 202009-2900-006
Status: Historical Active	Previous ICR Reference No: 201610-2900-003
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-MS
Title: Statement in Support of Claim for Service Connection for PTSD (VA Form 21-0781), Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault (VA Form 21-0781a)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/02/2021
	Date Received in OIRA: 03/05/2021
Terms of Clearance: In the next revision, extension, or reinstatement request: 1. Please explore whether survivors of sexual assault can use copies of prior descriptions/records, police complaints, etc. in lieu of completing a description of the assault on this form. 2. Modify "Your obligation to respond is voluntary" to "Your response is voluntary."

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2024	36 Months From Approved
Responses	20,374	0	0
Time Burden (Hours)	23,770	0	0
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	20,374	5,134	15,240
Annual Time Burden (Hours)	23,770	5,990	17,780
Annual Cost Burden (Dollars)	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 has increased due to the estimated number of receivables averaged over the past year.

Annual Cost to Federal Government: $1,282,991

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

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? No

Agency Contact: Maribel Aponte 202 266-4688 maribel.aponte@va.gov

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