Ankle Conditions Disability Benefits Questionnaire (21-0960M-2)

ICR 201304-2900-008

OMB: 2900-0806

Federal Form Document

Forms and Documents
Document
Name
Status
Form
New
Supplementary Document
2014-01-13
Supplementary Document
2014-01-06
Supporting Statement A
2014-04-10
IC Document Collections
ICR Details
2900-0806 201304-2900-008
Historical Active
VA 2900-NEW VBA-COMP-DB
Ankle Conditions Disability Benefits Questionnaire (21-0960M-2)
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 04/14/2014
Retrieve Notice of Action (NOA) 01/30/2014
  Inventory as of this Action Requested Previously Approved
04/30/2017 36 Months From Approved
30,000 0 0
15,000 0 0
0 0 0

The form 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 benefits.

US Code: 38 USC 501(a) Name of Law: Rules and Regulations
  
None

Not associated with rulemaking

  78 FR 111 06/10/2013
78 FR 221 11/15/2013
No

1
IC Title Form No. Form Name
Ankle Conditions Disability Benefits Questionnaire (21-0960M-2) 21-0960M-2 Ankle Conditions Disability Benefits Questionnaire

  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 30,000 0 0 30,000 0 0
Annual Time Burden (Hours) 15,000 0 0 15,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
There is no burden increase. The initial Information Collection Request (ICR) for the VAF 21-0960 series (71 forms) was consolidated under five Office of Management and Budget (OMB) control numbers (2900-0749, 2900-07769, 2900-0778, 2900-0779, and 2900-0781). OMB Control Number 2900-0776, which expires March 15, 2015, currently contains VA Form 21-0960M-2, Ankle Conditions Disability Benefits Questionnaire. VA proposes to remove this information collections (IC) from control number 2900-0776 and have it assigned a new individual control number. VA will retain all other ICs under OMB control numbers 2900-0776 until pending substantive revisions are complete. At which time, VA will request separate OMB control numbers for each IC in the VA Form 21-0960 series and discontinue OMB control number 2900-0776. This change is necessary to provide VA with the flexibility to modify each form on an individual basis instead of limiting the changes to the original five groupings. VA needs the maximum flexibility because the content of the form is influenced by a multitude of unpredictable forces outside its control. As such, VA needs to maximize its ability to modify the forms consistent with the form contents' dynamic environment. This change will not increase the respondent burden

$1,758,450
No
No
No
No
No
Uncollected
Crystal Rennie 202 632-7492 crystal.rennie@va.gov

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
01/30/2014


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