Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)

Forms and Documents

Document Name	Status
Form 21-0960M-12 Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12) Form	New
OMB21-0960M-12(3-27-14).doc Supporting Statement A	2014-03-27

IC Document Collections

IC ID	Document Title	Status
206614	Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12) Form	New

ICR Details

OMB Control No: 2900-0802	ICR Reference No: 201304-2900-029
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: 2900-NEW VBA-COMP-DB
Title: Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/07/2014
	Date Received in OIRA: 11/25/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved
Responses	50,000	0	0
Time Burden (Hours)	25,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 38 USC 501(a) Name of Law: Rules and Regulations
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 116	06/17/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 211	10/31/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)	21-0960M-12	Shoulder and Arm Conditions Disability Benefits Questionnaire

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ICR Summary of Burden

	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	50,000	0	0	50,000	0	0
Annual Time Burden (Hours)	25,000	0	0	25,000	0	0
Annual Cost Burden (Dollars)	0	0	0	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 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-12, Shoulder and Arm Conditions Disability Benefits Questionnaire. VA proposes to remove this information collection (IC) from control number 2900-0776 and have it assigned a new individual control number. VA will retain all other ICs under OMB control number 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. 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.

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Annual Cost to Federal Government: $2,930,750

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 11/25/2013

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