Disability Benefits Questionnaires (Group 3)

ICR 201402-2900-001

OMB: 2900-0778

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2014-11-13
Supplementary Document
2014-08-20
Supporting Statement A
2015-06-18
IC Document Collections
IC ID
Document
Title
Status
196002 Modified
ICR Details
2900-0778 201402-2900-001
Historical Active 201201-2900-007
VA 2900-0778 VBA-COMP-DB
Disability Benefits Questionnaires (Group 3)
Revision of a currently approved collection   No
Regular
Approved with change 06/22/2015
Retrieve Notice of Action (NOA) 11/18/2014
This ICR is approved for one year. Upon the next submission of this ICR for OMB approval, VA must address all substantive and non-substantive comments that were submitted by Lockheed Martin in response to the Federal Register Notice for this ICR that was published on August 15, 2014.
  Inventory as of this Action Requested Previously Approved
06/30/2016 36 Months From Approved 06/30/2015
250,000 0 350,000
77,500 0 102,500
0 0 0

This form is used to assist veteran's who require a disability examination in support of a claim for VA benefits. The forms are used to record the findings of the examining physician.

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

Not associated with rulemaking

  79 FR 158 08/15/2014
79 FR 219 11/13/2014
Yes

1
IC Title Form No. Form Name
Disability Benefits Questionnaires (Group 3) VA Form 21-0960G-4, VA Form 21-0960C-5, VA Form 21-0960G-8, VA Form 21-0960H-2, VA Form 21-0960G-5, VA Form 21-0960G-7, VA Form 21-0960M-11, VA Form 21-0960K-2, VA Form 21-0960L-2, VA Form 21-0960K-1, VA Form 21-0960C-8, VA Form 21-0960G-2, VA Form 21-0960C-9, VA Form 21-0960G-1, VA Form 21-0960N-1, VA Form 21-0960G-3, VA Form 21-0960G-6 Hepatitis, Cirrhosis and other Liver Conditions Disability Benefits Questionnaire ,   Stomach and Duodenal Conditions (Not including GERD or Esophageal Disorders) Disability Benefits Questionnaire ,   Ear Conditions (Including Vestibular and Infectious Conditions) Disability Benefits Questionnaire ,   Rectum and Anus Conditions Conditions (Including Hemorrhoids) Disability Benefits Questionnaire ,   Peritoneal Adhesions Disability Benefits Questionnaire ,   Intestinal Conditions (Other than Surgical or Infectious) (Including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis, and Diverticulitis) Disability Benefits Questionnaire ,   Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire ,   Central Nervous System and Neuromuscular Diseases ,   Infectious Intestinal Disorders, Including Bacterial and Parasitic Infections Disability Benefits Questionnaire ,   Osteomyelitis Disability Benefits Questionnaire ,   Gynecological Conditions Disability Benefits Questionnaire ,   Sleep Apnea Disability Benefits Questionnaire ,   Breast Conditions and Disorders Disability Benefits Questionnaire ,   Headaches (including migraine headaches) Disability Benefits Questionnaire ,   Gallbladder and Pancreas Conditions Disability Benefits Questionnaire ,   Esophageal Conditions (including gastroesophageal reflus disease (GERD), hiatal hernia and other esophageal disorders) Disability Benefits Questionnaire ,   Multiple Sclerosis (MS) 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 250,000 350,000 0 -100,000 0 0
Annual Time Burden (Hours) 77,500 102,500 0 -25,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
The reduction in cost to the government is due to recalculation of each IC in the series. VA Form 21-0960M-3 was also removed from this collection.

$8,787,710
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.
11/18/2014


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