OMB21-4176(11-24-08)

Supporting Statement for VA Form 21-4176

Report of Accidental Injury In Support of Claim for Compensation or Pension

(2900-0104)

A. Justification

1. The Department of Veterans Affairs (VA) through its Veterans Benefits Administration (VBA) administers an integrated program of benefits and services, established by law, for veterans, service personnel and their survivors. 38 U.S.C. 105, 1110, 1131, and 1521a state that compensation or pension shall not be paid for disabilities that are the result of a veteran’s own willful misconduct. Benefits may be paid if a disability is incurred in line of duty and is not the result of the veteran’s own willful misconduct under 38 C.F.R. 3.301.

2. VA Form 21-4176 is used in support of claims for disability benefits based on disability which is the result of an accident. The information given by the veteran is used as a source to gather specific data regarding the accident and to afford the veteran an opportunity to provide information from his or her own knowledge regarding the accident.

3. VA Form 21-4176 is available on the One-VA web site in a fillable electronic format. VBA is currently hosting this form on a secure server and does not currently have the technology in place to allow for the complete submission of the form. Validation edits are performed to assure data integrity. Efforts within VA are underway to provide a mechanism to allow the information to be submitted electronically with a recognized signature technology. There currently is no utility process in place that will allow the data submitted on the forms to be incorporated with an existing centralized legacy database. Veterans Online Applications (VONAPP) allows applicants to view, print, and submit applications electronically to VBA. However, VA Form 21-4176 is not one of the forms to be added to VONAPP because estimated total usage of this form is minimal. The Department will reconsider adding this form to VONAPP when the resources become available or if usage of this form becomes greater.

4. Program reviews were conducted to identify potential areas of duplication; however, none were found to exist. There is no known Department or Agency which maintains the necessary information, nor is it available from other sources within our Department.

5. The collection of information does not involve small businesses or entities.

6. Benefits are not payable where injury is the result of willful misconduct. Without the information provided on this form, it would not be possible to obtain the information needed to make a determination of whether or not the injury was the result of willful misconduct.

7. There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.

8. The Department notice was published in the Federal Register on June 3, 2008, pages 31738-31739. No comments were received.

9. No payments or gifts to respondents have been made under this collection of information.

10. The records are maintained in the appropriate Privacy Act System of Records identified as 58VA21/22, "Compensation, Pension, Education and Rehabilitation Records - VA" as set forth in Privacy Act Issuances, 2001 compilation.

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 4,408 per year.

b. Frequency of Response is one time for most beneficiaries.

c. Annual burden is 2,204 hours.

d. The estimated completion time of 30 minutes is based on review by staff personnel and previous usage of this form.

e. The total estimated cost to respondents is $33,060 (2,204 hours x $15 per hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $97,467

(GS-11/5 @ $31.61 x 4,408 x 15/60 minutes = $ 34,834)

(GS-9/5 @ $26.13 x 4,408 x 30/60 minutes = $57,590)

(GS-3/5 @ $13.73 x 4,400 x 5/60 minutes = $ 5,043)

b. Printing and production cost $165

c. Total cost to government $ 97,632

15. The reporting burden has not changed.

16. The information collection is not for publication or tabulation use.

17. The collection instrument, VA Form 21-4176, may be reproduced and/or stocked by the respondents and veterans service organizations. This VA form does not display an expiration date, and if required to do so would result in unnecessary waste of existing stocks of this form. This form is submitted to OMB every 3 years. As such, this date requirement would also result in an unnecessary burden on the respondents and would delay Department action on the benefit being sought. VA also seeks to minimize its cost to itself of collecting, processing and using the information by not displaying the expiration date. For the reasons stated, VA continues to seek an exemption that waives the displaying of the expiration date on VA Form 21-4176.

18. This submission does not contain any exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

1. The collect of information does not employ statistical methods.