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Request for Employment Information in Connection with Claim for Disability Benefits
Request for Employment Information in Connection with Claim for Disability Benefits
OMB: 2900-0065
IC ID: 28204
OMB.report
VA
OMB 2900-0065
ICR 201009-2900-020
IC 28204
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0065 can be found here:
2024-07-08 - Revision of a currently approved collection
2021-05-20 - Reinstatement with change of a previously approved collection
Documents and Forms
Document Name
Document Type
Form 21-4192
Request for Employment Information in Connection with Claim for Disability Benefits
Form
21-4192 Request for Employment Information in Connection with Cl
VA Form 21-4192.pdf
www.va.gov/vaforms/
Form
Information Collection (IC) Details
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.