Supporting Statement for VAF 21-0960 group 2 (9-3-14)

Supporting Statement for

VAF 21-0960A-2, Artery and Vein Conditions (vascular diseases including varicose veins) Disability Benefits Questionnaire

VAF 21-0960A-3, Hypertension Disability Benefits Questionnaire

VAF 21-0960A-4, Non-ischemic Heart Disease (including arrhythmias and surgery) Disability Benefits Questionaire

VAF 21-0960C-4, Diabetic Peripheral Neuropathy (diabetic sensory-motor peripheral neuropathy) Disability Benefits Questionnaire

VAF 21-0960E-1, Diabetes Mellitus Disability Benefits Questionnaire

VAF 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire

VAF 21-0960F-2 Skin Diseases Disability Benefits Questionnaire

VAF 21-0960M-1 Amputations Disability Benefits Questionnaire

VAF 21-0960M-10 Muscle Injuries Disability Benefits Questionnaire

VAF 21-0960M-15 Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire

VAF 21-0960N-2 Eye Conditions Disability Benefits Questionnaire

(2900-0776)

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) 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.

VA requested removal of VAF 21-0960M-2 Ankle Conditions Disability Benefits Questionnaire, VAF 21-0960M-4 Elbow and Forearm Conditions Disability Benefits Questionnaire, VAF 21-0960M-5 Flatfeet (pes planus) Disability Benefits Questionnaire, VAF 21-0960M-6 Foot Miscellaneous (other than flatfoot (pes planus)) Disability Benefits Questionnaire, VAF 21-0960M-7 Hand and Finger Conditions Disability Benefits Questionnaire, VAF 21-0960M-8 Hip and Thigh Conditions Disability Benefits Questionnaire, VAF 21-0960M-9 Knee and Lower Leg Conditions Disability Benefits Questionnaire, VAF 21-0960M-12 Shoulder and Arm Conditions Disability Benefits Questionnaire, VAF 21-0960M-16 Wrist Conditions Disability Benefits Questoionnaire from OMB Control No. 2900-0776 and have them assigned new individual control numbers. VA will retain all other ICs under OMB control number 2900-0776 until pending revisions are complete. At which time, VA will request separate OMB control numbers for each IC in the VA Form 21-0960 series under 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.

The expiration date is being added to the forms.

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 benefits.  The Disability Benefit Questionnaire title will include the name of the specific disability for which it will gather information. VAF 21-0960A-2, Artery and Vein Conditions vascular diseases including varicose veins) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of arteries, veins, and/or peripheral vascular disease; VAF 21-0960A-3, Hypertension, Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of hypertension; VAF 21-0960A-4, Non-ischemic Heart Disease (including Arrhythmias and Surgery) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any non-ischemic heart disease; VAF 21-0960C-4, Diabetic Peripheral Neuropathy (diabetic sensory-motor peripheral neuropathy) Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of a diabetic sensory-motor peripheral neuropathy condition; VAF 21-0960E-1, Diabetes Mellitus Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of diabetes mellitus; VAF 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of any scars or disfigurement; VAF 21-0960F-2, Skin Diseases Disability BenefitsQuestionnaire, will gather information related to the claimant’s diagnosis of any skin disease. VAF 21-0960M-1 Amputations Disability Benefits Questionnaire, will gather information related to the claimant’s amputations; VAF 21-0960M-10 Muscle Injuries Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a muscle injury disability. VAF 21-0960M-15 Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of temporomandibular joint dysfunction or TMJ. VAF 21-0960N-2 Eye Conditions Disability Benefits Questionnaire will gather information related to the claimant’s diagnosis of an eye condition.

3. VA Form 21-0960 series is available on the One-VA Website 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 form to be incorporated with an existing centralized legacy database..

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 January 17, 2014, Volume 79, No. 12, Pages 3275-3276. No comments were received in response to this notice.

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 Vocational Rehabilitation and Employment Records-VA (58VA21/22/28),” published at 74 FR 29275 on June 19, 2009, and last amended at 75 FR 22187 (April 27, 2010).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

a. Number of Respondents is estimated at 400,000 per year for all forms:

VAF 21-0960A-2 – 20,000

VAF 21-0960A-3 – 50,000

VAF 21-0960A-4 – 20,000

VAF 21-0960C-4 – 75,000

VAF 21-0960E-1 –75,000

VAF 21-0960F-1 – 25,000

VAF 21-0960F-2 – 25,000

VAF 21-0960M-1 – 25,000

VAF 21-0960M-10 – 30,000

VAF 21-0960M-15 – 15,000

VAF 21-0960N-2 – 40,000

b. Frequency of Response is on occasion for most beneficiaries.

c. Annual burden hours is 162,500 hours:

VAF 21-0960A-2 – 10,000

VAF 21-0960A-3 – 12,500

VAF 21-0960A-4 –10,000

VAF 21-0960C-4 – 37,500

VAR 21-0960E-1 – 18,750

VAF 21-0960F-1- 6,250

VAF 21-0960F-2 – 6,250

VAF 21-0960M-1 – 12,500

VAF 21-0960M-10 – 15,000

VAF 21-0960M-15 – 3,750

VAF 21-0960N-2 – 30,000

d. The estimated completion time for each form is as follows:

VAF 21-0960A-2 – 30 minutes

VAF 21-0960A-3 – 15 minutes

VAF 21-0960A-4 – 30 minutes

VAF 21-0960C-4 – 30 minutes

VAR 21-0960E-1 – 15 minutes

VAF 21-0960F-1 – 15 minutes

VAF 21-0960F-2 – 15 minutes

VAF 21-0960M-1 – 30 minutes

VAF 21-0960M-10 – 30 minutes

VAF 21-0960M-15 – 15 minutes

VAF 21-0960N-2 – 45 minutes

e. According to the U.S. Bureau of Labor Statistics Average Hourly Earnings, the cost to the respondent is $24, making the total cost to the respondents an estimated $3,900,000. (162,500 burden hours x $24 per hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

a. Processing/Analyzing costs $ 19,752,185

1. VAF 21-0960-A-2

(GS-13/5 @ $48.35 x 20,000 x 30/60 minutes = $483,500)

(GS-12/5 @ $40.66 x 20,000 x 30/60 minutes = $406,600)

(GS-9/5 @ $28.04 x 20,000 x 30/60 minutes = $280,400)

2. VAF 21-0960-A-3

(GS-13/5 @ $48.35 x 50,000 x 15/60 minutes = $604,375)

(GS-12/5 @ $40.66 x 50,000 x 15/60 minutes = $508,250)

(GS-9/5 @ $28.04 x 50,000 x 15/60 minutes = $350,500)

3. VAF 21-0960-A-4

((GS-13/5 @ $48.35 x 20,000 x 30/60 minutes = $483,500)

(GS-12/5 @ $40.66 x 20,000 x 30/60 minutes = $406,600)

(GS-9/5 @ $28.04 x 20,000 x 30/60 minutes = $280,400)

4. VAF 21-0960-C-4

(GS-13/5 @ $48.35 x 75,000 x 30/60 minutes = $1,813,125)

(GS-12/5 @ $40.66 x 75,000 x 30/60 minutes = $1,524,750)

(GS-9/5 @ $28.04 x 75,000 x 30/60 minutes = $1,051,500)

5. VAF 21-0960-E-1

(GS-13/5 @ $48.35 x 75,000 x 15/60 minutes = $906,562)

(GS-12/5 @ $40.66 x 75,000 x 15/60 minutes = $762,375)

(GS-9/5 @ $28.04 x 75,000 x 15/60 minutes = $525,750)

6. VA F 21-0960F-1

(GS-13/5 @ $48.35 x 25,000 x 15/60 minutes = $302,187)

(GS-12/5 @ $40.66 x 25,000 x 15/60 minutes = $254,125)

(GS-9/5 @ $28.04 x 25,000 x 15/60 minutes = $175,250)

7. VAF 21-0960-F-2

(GS-13/5 @ $48.35 x 25,000 x 15/60 minutes = $302,187)

(GS-12/5 @ $40.66 x 25,000 x 15/60 minutes = $254,125)

(GS-9/5 @ $28.04 x 25,000 x 15/60 minutes = $175,250)

8. VAF 21-0960-M-1

(GS-13/5 @ $48.35 x 25,000 x 30/60 minutes = $604,375)

(GS-12/5 @ $40.66 x 25,000 x 30/60 minutes = $508,250)

(GS-9/5 @ $28.04 x 25,000 x 30/60 minutes = $350,500)

9. VAF 21-0960-M-10

(GS-13/5 @ $48.35 x 30,000 x 30/60 minutes = $725,250)

(GS-12/5 @ $40.66 x 30,000 x 30/60 minutes = $609,900

(GS-9/5 @ $28.04 x 30,000 x 30/60 minutes = $420,600)

10. VAF 21-0960-M-15

(GS-13/5 @ $48.35 x 15,000 x 15/60 minutes = $181,312)

(GS-12/5 @ $40.66 x 15,000 x 15/60 minutes = $152,475)

(GS-9/5 @ $28.04 x 15,000 x 15/60 minutes = $105,150)

11. VAF 21-0960-N-2

(GS-13/5 @ $48.35 x 40,000 x 45/60 minutes = $1,450,500)

(GS-12/5 @ $40.66 x 40,000 x 45/60 minutes = $1,219,800)

(GS-9/5 @ $28.04 x 40,000 x 45/60 minutes = $841,200)

b. Printing and production cost $19,752

c. Total cost to government $ 19,771,937

15. The respondent burden is decreased because VA removed nine collections from this group. With the exception of the expiration date placeholder, there are no substantive revisions to the remaining information collections.

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

17. We are not seeking approval to omit the expiration date for OMB approval.

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

B. Collection of Information Employing Statistical Methods

The collection of information does not employ statistical methods.