2900-0791-Supporting Stmt, 8-21-14

Supporting Statement for

VA Form 21-0958

Notice of Disagreement

(2900-0791)

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. Information is requested by this form under the authority of 38 U.S.C. 1114, 1521(d) and (e), 1115(1)(E), 1311(d), 1541(d) and (e). Regulatory authority is found in Title 38 CFR 3.351, 3.351(d), 3.351 (d)(2), 3.351(c)(2), 4.16, and 3.326(a).

The Final Rule RIN 2900-AO81, Standard Claims and Appeals Forms, which requires all claims for benefits to be submitted on an application or form prescribed by the Secretary. VA is codifying its regulations to standardize the use of all VA forms, to include VA Form 21-0958.

The instructions on the form have been updated to reflect changes based on the AO81 Rule. This is a non-substantive change.

2. VA Form 21-0958 will be used by the Veteran to indicate disagreement with a decision issued by a Regional Office (RO) in order to initiate an appeal. Historically, VBA commenced a pilot program on March 1, 2012 and provided the NOD in all decision and notification letters at the pilot location. VAF 21-0958, Notice of Disagreement, is the first step in the appeal process.  The respondent may or may not continue with an appeal to the Board of Veterans Appeals (BVA).  If the veteran opts to continue to BVA for an appeal, this form will be included in the claim folder as evidence. VA will provide VA Form 21-0958 to claimants with the letter of the notification of the decision in paper form, via hyperlink to VA’s website, or through its electronic claims processing system. VA is proposing to codify the requirement of this form for claimants to initiate an appeal in order to streamline the appeals process for more accurate and efficient appeals processing.

3. VA Form 21-0958 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. There is no known Department or Agency which maintains the necessary information, nor is it available from other sources within our department. Although claimants may use the existing VA Form 21-4138 to report a disagreement with VA’s decision, the 21-4138 was not intended for this purpose. The form will provide the claimant with a prescribed form designed to file a Notice of Disagreement on specific issues of contention. The form will also allow VA to process NOD’s more efficiently.

5. The collection of information does not involve small businesses or entities.

6. This form is designed in a “user friendly” format, incorporating plain English, to comply with the President’s Memorandum of June 1, 1998, Plain Language in Government Writing.

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 proposed rule, RIN 2900-AO81, Standard Claims and Appeals Forms, in the Federal Register on October 31, 2013, pages 65490-65509. 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 58VA21/22/28, “Compensation, Pension, Education, and Vocational Rehabilitation and Employee Records—VA,” as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009), and last amended by 75 FR 22187 (April 27, 2010), with other amendments, as cited therein.

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

1. Number of Respondents estimated at 144,000 per year.

2. Frequency of Response is one time.

3. Annual burden is 72,000 hours.

4. The estimated completion time of 30 minutes.

5. 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 $1,728,000 (72,000 hours x $24/hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

1. Processing/Analyzing costs $ 7,216,560

(GS-13/5 @ $48.35 x 144,000 x 30/60 minutes = $3,481,200)

(GS-11/5 @ $33.92 x 144,000 x 30/60 minutes = $2,442,240)

(GS-5/5 @ $17.96 x 144,000 x 30/60 minutes = $1,293,120)

2. Printing and production cost ($90 per thousand) $17,412

3. Total cost to government $7,229,520

15. There is no change in responding burden even with Notice of Proposed Rulemaking (NPRM) RIN 2900-AO81, “Standard Claims and Appeals Forms” which proposes to require all claims for benefits to be submitted on an application or form prescribed by the Secretary. However, the estimated costs to the federal government have been revised to reflect updated data.

The instructions on the form have been updated to reflect changes based on the AO81 Rule. This is a non-substantive change.

The form includes an expiration date placeholder per OMB’s guidance.

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 data collection does not employ statistical methods.