Supporting Statement for
VAF 21-0960B-2 Hematologic and Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire
VAF 21-0960C-2, Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease) Disability Benefits Questionnaire
VAF 21-0960C-10, Peripheral Nerve Conditions (Not Including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire
VAF 21-0960I-1, Persian Gulf and Afghanistan Infectious Diseases Disability Benefits Questionnaire
VAF 21-0960I-6, Tuberculosis Disability Benefits Questionnaire
VAF 21-0960J-1, Kidney Conditions (Nephrology) Disability Benefits Questionnaire
VAF 21-0960J-2, Male Reproductive System Conditions Disability Benefits Questionnaire
VAF 21-0960J-3, Prostate Cancer Disability Benefits Questionnaire
VAF 21-0960M-13, Neck (Cervical Spine) Disability Benefits Questionnaire
VAF 21-0960M-14, Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire
VAF 21-0960P-1, Eating Disorders Disability Benefits Questionnaire
VAF 21-0960P-2, Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire
VAF 21-0960P-3, Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire
(2900-xxxx)
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 dependents and/or beneficiaries. 38 U.S.C. 501 (a), Rules and Regulations, authorizes VA to prescribe all rules and regulations which are necessary or appropriate to carry out the laws administered by the Department, including the methods of making medical examinations. 38 CFR 3.326 authorizes a VA examination where the reasonable probability of a valid claim is indicated in any claim for disability compensation or pension, including claims for benefits set forth under 38 C.F.R. 3.351(d) and (e), benefits based on the need of a veteran, surviving spouse, or parent for regular aid and attendance, and benefits based on a child's incapacity for self-support. VA Form 21-0960 series will be used for disability compensation or pension claims which require an examination.
2. The VA Form 21-0960 series will be used to gather necessary information from a claimant’s treating physician regarding the results of medical examinations. VA will gather medical information related to the claimant that is necessary to adjudicate the claim for VA disability benenfits. The Disability Benefit Questionnaire title will include the name of the specific disability for which it will gather information. VAF 21-0960B-2, Hematologic and Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any hematologic or lymphatic condition; VAF 21-0960C-2, Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of amyotrophic lateral sclerosis; VAF 21-0960C-10, Peripheral NerveConditions (Not Including Diabetic Sensory-Motor Peripheral neuropathy) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a peripheral nerve disorder; VAF 21-0960I-1, Persian Gulf and Afghanistan Infectious Diseases Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of an infectious disease due to service in the Persian Gulf or Afghanistan; VAF 210960-I-6, Tuberculosis Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of tuberculosis; VAF 21-0960J-1, Kidney Conditions (Nephrology) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of kidney disease; VAF 21-0960J-2, Male Reproductive System Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a condition affecting the male reproductive organ; VAF 21-0960J-3, Prostate Cancer Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of prostate cancer; VAF 21-0960M-13, Neck (Cervical Spine) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a cervical spine condition; VAF 21-0960M-14, Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a thoracic or lumbar spine condition; VAF 21-0960P-1, Eating Disorders Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of an eating disorder; VAF 21-0960P-2, Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of any mental disorder with the exception of PTSD and Eating Disorders; VAF 21-0960P-3, Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of PTSD.
3. The collection of information does not involve the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology. Veterans Online Applications (VONAPP) allows applicants to view, print and submit applications electronically to VBA; however, the Department is not planning to add VA Form 21-0960 series to VONAPP as they are completed by the examining physican.
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. The VA compensation and pension programs require current information to determine initial and continuing eligibility for benefits. This form solicits the information needed to determine the level of disability. Without this information, benefits could not be administered effectively.
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 February 15, 2011, pages 8846-8847. 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 ‘‘Compensation, Pension, Education, and Rehabilitation Records—VA (58VA21/22/28)’’as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009).
11. There are no questions of a sensitive nature.
12. Estimate of Information Collection Burden.
a. Number of Respondents is estimated at 407,000 per year for all forms:
VAF 21-0960B-2 - 10,000
VAF 21-0960C-2 – 2,000
VAF 21-0960C-10 – 55,000
VAF 21-0960I-1 – 50,000
VAF 21-0960I-6 – 5,000
VAF 21-0960J-1 – 25,000
VAF 21-0960J-2 – 25,000
VAF 21-0960-J-3 - 25,000
VAF 21-0960M-13 – 50,000
VAF 21-0960M-14 – 50,000
VAF 21-0960P-1 – 5,000
VAF 21-0960P-2 – 50,000
VAF 21-0960P-3 – 55,000
b. Frequency of Response is on occasion for most beneficiaries.
c. Annual burden hours is 213,500 hours:
VAF 21-0960B-2 – 2,500
VAF 21-0960C-2 – 1,000
VAF 21-0960C-10 – 41,250
VAF 21-0960I-1 – 12,500
VAF 21-0960I-6 – 2,500
VAF 21-0960J-1 – 12,500
VAF 21-0960J-2 – 6,250
VAF 21-0960J-3 – 6,250
VAF 21-0960M-13 – 37,500
VAF 21-0960M-14 – 37,500
VAF 21-0960P-1 – 1,250
VAF 21-0960P-2 – 25,000
VAF 21-0960P-3 – 27,500
d. The estimated completion time for each form is as follows:
VAF 21-0960B-2 – 15 minutes
VAF 21-0960C-2 – 30 minutes
VAF 21-0960C-10 – 45 minutes
VAF 21-0960I-1 – 15 minutes
VAF 21-0960I-6 – 30 minutes
VAF 21-0960J-1 – 30 minutes
VAF 21-0960J-2 – 15 minutes
VAF 21-0960J-3 - 15 minutes
VAF 21-0960M-13 – 45 minutes
VAF 21-0960M-14 – 45 minutes
VAF 21-0960P-1 – 15 minutes
VAF 21-0960P-2 – 30 minutes
VAF 21-0960P-3 – 30 minutes
e. The total estimated cost to respondents is $3,202,500 (219,750 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 $ 303,393,600
VAF 21-0960-B-2
(GS-13/5 @ $48.35 x 432,000 x 15/60 minutes = $5,221,800)
(GS-12/5 @ $40.66 x 432,000 x 15/60 minutes = $4,391,280)
(GS-9/5 @ $28.04 x 432,000 x 15/60 minutes = $3,028,320)
VAF 21-0960-C-2
(GS-13/5 @ $48.35 x 432,000 x 30/60 minutes = $10,443,600)
(GS-12/5 @ $40.66 x 432,000 x 30/60 minutes = $ 8,782,560)
(GS-9/5 @ $28.04 x 432,000 x 30/60 minutes = $ 6,056,640)
VAF 21-0960-C-10
(GS-13/5 @ $48.35 x 432,000 x 45/60 minutes = $15,665,400)
(GS-12/5 @ $40.66 x 432,000 x 45/60 minutes = $13,173,840)
(GS-9/5 @ $28.04 x 432,000 x 45/60 minutes = $ 9,084,960)
VAF 21-0960-I-1
(GS-13/5 @ $48.35 x 432,000 x 15/60 minutes = $5,221,800)
(GS-12/5 @ $40.66 x 432,000 x 15/60 minutes = $4,391,280)
(GS-9/5 @ $28.04 x 432,000 x 15/60 minutes = $3,028,320)
VAF 21-0960-I-6
(GS-13/5 @ $48.35 x 432,000 x 30/60 minutes = $10,443,600)
(GS-12/5 @ $40.66 x 432,000 x 30/60 minutes = $ 8,782,560)
(GS-9/5 @ $28.04 x 432,000 x 30/60 minutes = $ 6,056,640)
VAF 21-0960-J-1
(GS-13/5 @ $48.35 x 432,000 x 30/60 minutes = $10,443,600)
(GS-12/5 @ $40.66 x 432,000 x 30/60 minutes = $ 8,782,560)
(GS-9/5 @ $28.04 x 432,000 x 30/60 minutes = $ 6,056,640)
VAF 21-0960-J-2
(GS-13/5 @ $48.35 x 432,000 x 15/60 minutes = $5,221,800)
(GS-12/5 @ $40.66 x 432,000 x 15/60 minutes = $4,391,280)
(GS-9/5 @ $28.04 x 432,000 x 15/60 minutes = $3,028,320)
VAF 21-0960-J-3
(GS-13/5 @ $48.35 x 432,000 x 15/60 minutes = $5,221,800)
(GS-12/5 @ $40.66 x 432,000 x 15/60 minutes = $4,391,280)
(GS-9/5 @ $28.04 x 432,000 x 15/60 minutes = $3,028,320)
VAF 21-0960-M-13
(GS-13/5 @ $48.35 x 432,000 x 45/60 minutes = $15,665,400)
(GS-12/5 @ $40.66 x 432,000 x 45/60 minutes = $13,173,840)
(GS-9/5 @ $28.04 x 432,000 x 45/60 minutes = $ 9,084,960)
VAF 21-0960-M-14
(GS-13/5 @ $48.35 x 432,000 x 45/60 minutes = $15,665,400)
(GS-12/5 @ $40.66 x 432,000 x 45/60 minutes = $13,173,840)
(GS-9/5 @ $28.04 x 432,000 x 45/60 minutes = $ 9,084,960)
VAF 21-0960-P-1
(GS-13/5 @ $48.35 x 432,000 x 15/60 minutes = $5,221,800)
(GS-12/5 @ $40.66 x 432,000 x 15/60 minutes = $4,391,280)
(GS-9/5 @ $28.04 x 432,000 x 15/60 minutes = $3,028,320)
VAF 21-0960-P-2
(GS-13/5 @ $48.35 x 432,000 x 30/60 minutes = $10,443,600)
(GS-12/5 @ $40.66 x 432,000 x 30/60 minutes = $ 8,782,560)
(GS-9/5 @ $28.04 x 432,000 x 30/60 minutes = $ 6,056,640)
VAF 21-0960-P-3
(GS-13/5 @ $48.35 x 432,000 x 30/60 minutes = $10,443,600)
(GS-12/5 @ $40.66 x 432,000 x 30/60 minutes = $ 8,782,560)
(GS-9/5 @ $28.04 x 432,000 x 30/60 minutes = $ 6,056,640)
b. Printing and production cost $9,000
c. Total cost to government $ 303,402,600
15. This is a new information collection.
16. The information collection is not for publication or tabulation use.
17. The collection instrument, VA Form 21-0960 series may be reproduced and/or stocked by the respondents and veterans service organizations. These VA forms do not display an expiration date, and if required to do so would result in unnecessary waste of existing stocks of the forms. These 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 seeks an exemption that waives the displaying of the expiration date on VA Form 21-0960 series
18. This submission does not contain any exceptions to the certification statement.
B. Collection of Information Employing Statistical Methods
The data collection does not employ statistical methods.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SF 83 SS VAF 21-8926 |
| Author | Veterans Benefits Administrat |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |