Supporting Statement for VA Form 21P-4176
Report of Accidental Injury In Support of Claim for Compensation or
Pension/Statement of Witness to Accident
(2900-0104)
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 survivors. 38 U.S.C. 105, 1110, 1131, and 1521a state that compensation or pension shall not be paid for disabilities that are the result of a veteran's own willful misconduct. Benefits may be paid if a disability is incurred in line of duty and is not the result of the veteran’s own willful misconduct under 38 C.F.R. 3.301. This form is being transferred from Compensation Service to Pension and Fiduciary Service, due to changes in business lines.
There was an error on the 60-day and 30-day Federal Register Notices. The number of respondents should have been 4,408 and the annual burden hours should have been 2,204.
2. VA Form 21P-4176 is used in support of claims for disability benefits based on disability which is the result of an accident. The information given by the veteran is used as a source to gather specific data regarding the accident and to afford the veteran an opportunity to provide information from his or her own knowledge regarding the accident.
3. VA Form 21P-4176 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. Benefits are not payable where injury is the result of willful misconduct. Without the information provided on this form, it would not be possible to obtain the information needed to make a determination of whether or not the injury was the result of willful misconduct.
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 August 28, 2014, Volume 79, No. 167, page 51398. 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 58VA21/22/28, ‘‘Compensation, Pension, Education, and Rehabilitation Records—VA ’’as set forth in Privacy Act Issuances, 1993 compilation found in 74 Fed. Reg. 117 (June 19, 2009).
11. There are no questions of a sensitive nature.
12. Estimate of Information Collection Burden.
a. Number of Respondents: 4,408 per year
b. Frequency of Response: one time
c. Annual Burden Hours: 2,204 hours
d. Estimated Completion Time: 30 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 $52,896. (2,204 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 $104,591
(GS-11/5 @ $33.92 x 4,408 x 15/60 minutes = $37,380)
(GS-9/5 @ $28.04 x 4,408 x 30/60 minutes = $61,800)
(GS-3/5 @ $14.73 x 4,408 x 5/60 minutes = $ 5,411)
b. Total cost to government $104,591
15. There are no changes to the respondent burden. The expiration date is being added to form.
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
This collection of information does not employ statistical methods.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement for VA Form 21-4502 |
| Author | VBA |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |