Disability Benefits Questionnaires (Group 2)

OMB: 2900-0776

IC ID: 195946

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0776 can be found here:

2018-02-06 - Reinstatement with change of a previously approved collection

Documents and Forms

Document Name Document Type
Form VA Form 21-0960A-2 Disability Benefits Questionnaires (Group 2) Form
VA Form 21-0960A-2 Artery and Vein Conditions (Vascular Diseases including 21-0960A-2.pdf www.va.gov/vaforms Form
VA Form 21-0960F-1 Scars/Disfigurement Disability Benefits Questionnaire 21-0960F-1.pdf www.va.gov/vaforms Form
VA Form 21-0960M-1 Temporomandibular Joint (TMJ) Conditions Disability Bene 21-0960M-15.pdf www.va.gov/vaforms Form
VA Form 21-0960A-4 Heart Conditions (Including Ischemic and Non-Ischemic He 21-0960A-4.pdf www.va.gov/vaforms Form
VA Form 21-0960C-4 Diabetic Sensory-Motor Peripheral Neuropathy Disability 21-0960C-4.pdf www.va.gov/vaforms Form
VA Form 21-0960N-2 Eye Conditions Disability Benefits Questionnaire 21-0960N-2.pdf www.va.gov/vaforms Form
VA Form 21-0960A-3 Hypertension Disability Benefits Questionnaire 21-0960A-3.pdf www.va.gov/vaforms Form
VA Form 21-0960M-1 Amputations Disability Benefits Questionnaire 21-0960M-1.pdf www.va.gov/vaforms Form
VA Form 21-0960F-2 Skin Diseases Disability Benefits Questionnaire 21-0960F-2.pdf www.va.gov/vaforms Form
VA Form 21-0960M-1 Muscle Injuries Disability Benefits Questionnaire 21-0960M-10.pdf www.va.gov/vaforms Form
VA Form 21-0960E-1 Diabetes Mellitus Disability Benefits Questionnaire 21-0960E-1.pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Disability Benefits Questionnaires (Group 2)	Agency IC Tracking Number:	2900-0776 VBA-COMP-DB

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-0960A-2	Artery and Vein Conditions (Vascular Diseases including Varicose Veins) Disability Benefits Questionnaire	21-0960A-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960F-1	Scars/Disfigurement Disability Benefits Questionnaire	21-0960F-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-15	Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire	21-0960M-15.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960A-4	Heart Conditions (Including Ischemic and Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) Disability Benefits Questionnaire	21-0960A-4.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-4	Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire	21-0960C-4.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960N-2	Eye Conditions Disability Benefits Questionnaire	21-0960N-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960A-3	Hypertension Disability Benefits Questionnaire	21-0960A-3.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-1	Amputations Disability Benefits Questionnaire	21-0960M-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960F-2	Skin Diseases Disability Benefits Questionnaire	21-0960F-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-10	Muscle Injuries Disability Benefits Questionnaire	21-0960M-10.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960E-1	Diabetes Mellitus Disability Benefits Questionnaire	21-0960E-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title: Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28)	FR Citation: 75 FR 22187

Number of Respondents: 400,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	400,000	-325,000	725,000
Annual IC Time Burden (Hours)	162,500	-148,750	311,250
Annual IC Cost Burden (Dollars)	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.