SuppStmt, 2900-0065-VAF 21-4192 (8-12-14)

Supporting Statement for:

(2900-0065)

VA Form 21-4192

Request for Employment Information in Connection with Claim for Disability Benefits

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. 1502 and 38 CFR 3.340 through 3.342.

VA is redesigning the current VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, December 2010. VA Form 21-4192 is the prescribed form to gather necessary employment information from Veterans’ employers so VA can determine eligibility to increased disability benefits based on unemployability. VA is modifying the form to include Reserve and National Guard data collection information. Reserve and National Guard duty is considered employment. This redesign does not increase the respondent burden. The expiration date placeholder has been added to the form.

2. VA Form 21-4192 is used to gather necessary employment information from veterans’ employers so VA can determine eligibility to increased disability benefits based on unemployability.

3. VA Form 21-4192 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 form used to collect the information is brief and can be completed by any employer including small businesses.

6. The VA compensation and pension programs require the actual termination date of the claimant’s employment and reason for termination in order to determine effective dates and entitlement in unemployability cases. These forms solicit such evidence.

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 May 30, 2014, Volume 79, No. 104, pages 31182 and 31183. 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 77 FR 42593 (July 19, 2012).

11. There are no questions of a sensitive nature.

12. Estimate of Information Collection Burden.

1. Number of yearly respondents totals = 60,000.

2. Frequency of Response is one time.

3. Annual burden total = 15,000 hours.

4. The estimated completion time is:

1. 15 minutes for VA Form 21-4192.

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 $360,000 (15,000 burden hours x $24 per hour).

13. This submission does not involve any recordkeeping costs.

14. Estimated Costs to the Federal Government:

1. Processing/Analyzing costs $1,366,800

(GS-12/5 @ $48.35 x 60,000 x 15/60 minutes = $725,250)

(GS-9/5 @ $28.04 x 60,000 x 15/60 minutes = $420,600)

(GS-3/5 @ $14.73 x 60,000 x 15/60 minutes = $220,950)

2. Printing and production cost $5,490

3. Total cost to government $1,372,290

15. VA is redesigning the current VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, December 2010. VA Form 21-4192 is the prescribed form to gather necessary employment information from Veterans’ employers so VA can determine eligibility to increased disability benefits based on unemployability. VA is modifying the form to include Reserve and National Guard data collection information. Reserve and National Guard duty is considered employment. This redesign does not increase the respondent burden.

The form has been updated to include an expiration date placeholder.

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.