OMB 2900-0778
VA Form 21-0960C-5 |
Central Nervous System and Neuromusculo Diseases Disability Benefits Questionnaire |
VA Form 21-0960C-8 |
Headaches (Including Migraine Headaches) Disability Benefits Questionnaire |
VA Form 21-0960C-9 |
Multiple Sclerosis (MS) Disability Benefits Questionnaire |
VA Form 21-0960G-1 |
Esophageal Disorder (including GERD, Hiatal Hernia and Other Esophageal Disorders Disability Benefits Questionnaire |
VA Form 21-0960G -2 |
Gall Bladder and Pancreas Conditions Disability Benefits Questionnaire |
VA Form 21-0960G-3 |
Intestinal Conditions (Other than Surgical or Infectious) Including Irritable Bowel Syndrome, Crohn’s Disease, Ulcerative Colitis, and Diverticulitis Disability Benefits Questionnaire |
VA Form 21-0960G-4 |
Infectious Intestinal Disorders (including Bacterial and Parasitic Infections) Disability Benefits Questionnaire |
VA Form 21-0960G-5 |
Hepatitis, Cirrhosis, and other Liver Conditions Disability Benefits Questionnaire |
VA Form 21-0960G-6 |
Peritoneal Adhesions Disability Benefits Questionnaire |
VA Form 21-0960G-7 |
Stomach and Duodenum Conditions (Not Including GERD or Esophageal Disorders) Disability Benefits Questionnaire |
VA Form 21-0960G-8 |
Intestinal Surgery (Bowel Resection, Colostomy and Ileostomy) Disability Benefits Questionnaire |
VA Form 21-0960H-2 |
Rectum and Anus Conditions (Including Hemorrhoids) Disability Benefits Questionnaire |
VA Form 21-0960K-1 |
Breast Conditions and Disorders Disability Benefits Questionnaire |
VA Form 21-0960K-2 |
Gynecological Conditions Disability Benefits Questionnaire |
VA Form 21-0960L-2 |
Sleep Apnea Disability Benefits Questionnaire |
VA Form 21-0960M-11 |
Osteomyelitis Disability Benefits Questionnaire |
VA Form 21-0960-N-1 |
Ear Conditions (Including Vestibular and Infectious) Disability Benefits Questionnaire |
JUSTIFICATION:
Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
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. 38 U.S.C. 501 (a), Rules and Regulations, authorizes VA to prescribe all rules and regulations which are necessary or appropriate to carry out the laws administered by the Department, including the methods of making medical examinations. 38 CFR 3.326 authorizes a VA examination where the reasonable probability of a valid claim is indicated in any claim for disability compensation or pension, including claims for benefits set forth under 38 C.F.R. 3.351(d) and (e), benefits based on the need of a veteran, surviving spouse, or parent for regular aid and attendance, and benefits based on a child's incapacity for self-support This provision also stipulates that medical evidence such as hospital reports or any examination reports, from any government or private institution may be accepted for rating a claim without further examination. The VA Form 21-0960 series (disability benefits questionnaires) will be used for disability compensation or pension claims which require an examination and/or receiving private medical evidence that may potentially be sufficient for rating purposes. The disability benefits questionnaires (DBQs) will streamline the process by which a Veteran submits relevant medical evidence to VBA for the purpose of rating disabilities in order to provide timely delivery of benefits to our Nation’s Veterans. The straightforward and standardized questions in the DBQs will improve the quality and timeliness of medical evidence necessary to support a Veteran’s claim for disability benefits, which will enable VA to adjudicate claims faster. The DBQs will, in some circumstances, facilitate a Veteran’s application for disability benefits by engaging a treating physician to aid in administering the C&P examination. Use of the streamlined medical questionnaires by private physicians, at the request of Veterans, as well as by VA contractors and VHA physicians, will create an aggregate timeliness advantage for claims processing and thus help alleviate the claims backlog. Leveraging resources of the private medical community will also enable VHA to redirect physician efforts to care and treatment.
Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.
The VA Form 21-0960 series will be used to gather necessary information from a claimant’s treating physician regarding the results of medical examinations. VA will gather medical information related to the claimant that is necessary to adjudicate the claim for VA disability benefits. The DBQ title will include the name of the specific disability for which it will gather information. VAF 21-0960C-5, Central Nervous System and Neuromusculo Diseases Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a central nervous system disease; VAF 21-0960C-8, Headaches (Including Migraine Headaches) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of headaches; VAF 21-0960C-9, Multiple Sclerosis (MS) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of multiple sclerosis; VAF 21-0960G-1, Esophageal Disorders (including GERD, Hiatal Hernia, and Other Esophageal Disorders) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any esophageal disorders; VAF 21-0960G-2, Gall Bladder and Pancreas Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any gall bladder and pancreas condition; VAF 21-0960G-3, Intestinal Conditions (Other than Surgical or Infectious) Including Irritable Bowel Syndrome, Crohn’s Disease, Ulcerative Colitis, and Diverticulitis Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any intestinal conditions unrelated to surgery or infection; VAF 21-0960G-4, Infectious Intestinal Disorders (including Bacterial and Parasitic Infections) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any infectious intestinal condition; VAF 21-0960G-5, Hepatitis, Cirrhosis and other Liver Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any liver condition; VAF 21-0960G-6, Peritoneal Adhesions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of peritoneal adhesions; VAF 21-0960G-7, Stomach and Duodenum Conditions (Not Including GERD or Esophageal Disorders) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any stomach or duodenum conditions; VAF 21-0960G-8, Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any surgical intestinal condition; VAF 21-0960H-2, Rectum and Anus Conditions (Including Hemorrhoids) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any rectum or anus condition, which includes hemorrhoids; VAF 21-0960K-1 Breast Conditions and Disorders Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a breast condition or disorder; VAF 21-0960K-2 Gynecological Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of a gynecological condition; VAF 21-0960L-2, Sleep Apnea Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of sleep apnea; VAF 21-0960M-11, Osteomyelitis Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of osteomyelitis; VAF 21-0960N-1, Ear Conditions (Including Vestibular and Infectious) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of an ear disease.
Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.
These VA forms are 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. 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.
Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.
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. Once a claim is received, VA has a duty to assist the Veteran in obtaining all necessary evidence to substantiate their claim. Based upon this duty, VA requests all pertinent medical evidence from the Veteran, any Federal Agencies that may have this evidence, any agency or entity which the Veteran has indicated may have this evidence and from which the Veteran has authorized VA to request the information, as well as VA medical evidence. Once evidence has been found to establish an in-service injury or disease, VA will evaluate to determine if there is sufficient current medical evidence to link a current diagnosis to the service-related injury or disease and rate the disability according to current symptomatology by using the rating schedule criteria in 38 CFR Part 4. For internal VA purposes, the DBQs have replaced the current VA examination process in order to obtain the essential medical evidence needed to rate the claim. The forms being used publicly also benefit both the Veteran and VA by providing the necessary relevant medical evidence without the need to request and obtain a VA examination, thus expediting the process for a swift decision. While the potential for duplication of evidence has long existed to some extent with any evidence received, DBQs do not add any new areas of potential duplication; if a DBQ is received then a VA examination will not be required.
If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.
The collection of information does not involve small businesses or entities. However, in an effort to assist the entities of the physicians who are required to complete these questionnaires, VA will maintain a web portal internet website. This site will provide private physicians with a paperless way to fill out and submit pertinent medical evidence.
Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.
The VA compensation and pension programs require current information to determine initial and continuing eligibility for benefits. This form solicits the information needed to determine the level of disability. Without this information, benefits could not be administered effectively. The provisions of 38 CFR § 3.159 state that in a claim for disability compensation, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record, if VA determines it is necessary to decide the claim. A medical examination or opinion is necessary if there is evidence that the Veteran suffered an event, injury or disease in service, or has a disease or symptoms of a disease listed in §§ 3.309, 3.313, 3.316, and 3.317, which manifested during an applicable presumptive period, provided the Veteran has the required service or triggering event to qualify for that presumption, and the information and evidence of record does not contain sufficient competent medical evidence to decide the claim. If the Veteran chooses to have his or her private physician complete a DBQ in lieu of a VA examination, the DBQ will solicit the information needed, per rating schedule criteria, to determine the level of disability without the need to schedule a VA medical examination.
Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.
There is no special circumstance requiring collection in a manner inconsistent with 5 CFR 1320.6 guidelines.
A. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.
The Department notice was published in the Federal Register on February 17, 2016, Volume 81, No. 31, pages 8129 and 8130. No comments were received in response to this notice.
A comment was received previously during the extension submitted in FY2015. The comments/responses per form listed in the table above in this grouping have resulted in both substantive and non-substantive changes. A supplemental document has been attached to this information collection.
Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.
This submission does not involve any recordkeeping costs.
Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payments or gifts to respondents have been made under this collection of information.
Describe any assurance of privacy to the extent permitted by law provided to respondents and the basis for the assurance in statute, regulation, or agency policy.
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).
Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
There are no questions of a sensitive nature.
Estimate of the hour burden of the collection of information:
Number of Respondents is estimated at 250,000 per year for all forms:
VAF 21-0960C-5 – 10,000
VAF 21-0960C-8 – 15,000
VAF 21-0960C-9 – 10,000
VAF 21-0960G-1 – 40,000
VAF 21-0960G-2 – 5,000
VAF 21-0960G-3 – 5,000
VAF 21-0960G-4 – 5,000
VAF 21-0960G-5 – 10,000
VAF 21-0960G-6 – 5,000
VAF 21-0960G-7 – 10,000
VAF 21-0960G-8 – 5,000
VAF 21-0960H-2 – 10,000
VAF 21-0960K-1 – 30,000
VAF 21-0960K-2 – 20,000
VAF 21-0960L-2 – 5,000
VAF 21-0960M-11 – 40,000
VAF 21-0960N-1 – 25,000
The estimated completion time for each form is as follows:
VAF 21-0960C-5 – 30 minutes
VAF 21-0960C-8 – 15 minutes
VAF 21-0960C-9 – 45 minutes
VAF 21-0960G-1 – 15 minutes
VAF 21-0960G-2 – 15 minutes
VAF 21-0960G-3 – 15 minutes
VAF 21-0960G-4 – 15 minutes
VAF 21-0960G-5 – 30 minutes
VAF 21-0960G-6 – 15 minutes
VAF 21-0960G-7 – 15 minutes
VAF 21-0960G-8 – 15 minutes
VAF 21-0960H-2 – 15 minutes
VAF 21-0960K-1 – 15 minutes
VAF 21-0960K-2 – 30 minutes
VAF 21-0960L-2 – 15 minutes
VAF 21-0960M-11 – 15 minutes
VAF 21-0960N-1 – 15 minutes
Annual burden hours is estimated at 77,500 burden hours:
VAF 21-0960C-5 – 5,000
VAF 21-0960C-8 – 3,750
VAF 21-0960C-9 – 7,500
VAF 21-0960G-1 – 10,000
VAF 21-0960G -2 – 1,250
VAF 21-0960G-3 – 1,250
VAF 21-0960G-4 – 1,250
VAF 21-0960G-5 – 5,000
VAF 21-0960G-6 – 1,250
VAF 21-0960G-7 – 2,500
VAF 21-0960G-8 – 1,250
VAF 21-0960H-2 – 2,500
VAF 21-0960K-1 – 7,500
VAF 21-0960K-2 – 10,000
VAF 21-0960L-2 – 1,250
VAF 21-0960M-11 – 10,000
VAF 21-0960N-1 – 6,250
If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.
This request covers 17 forms. Frequency of Response is one time for each form.
Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14 of the OMB 83-I.
The respondent population for VA Form 21-0960 series included in this grouping is composed of individuals who may be receiving treatment from physicians regarding the results of their medical examinations. VBA cannot make further assumptions about the population of respondents because of the variability of factors such as the educational background and wage potential of respondents. Therefore, VBA used general wage data to estimate the respondents’ costs associated with completing the information collection.
The Bureau of Labor Statistics (BLS) gathers information on full-time wage and salary workers. According to the latest available BLS data, the median weekly earnings of full-time wage and salary workers are $809.00. Assuming a forty (40) hour work week, the median hourly wage is $20.23.
Legally, respondents may not pay a person or business for assistance in completing the information collection and a person or business may not accept payment for assisting a respondent in completing the information collection. Therefore, there are no expected overhead costs for completing the information collection. VBA estimates the total cost to all respondents to be $1,567,825.00 (77,500 burden hours x $20.23 per hour).
Provide an estimate of the total annual cost burden to respondents or record-keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).
There is no capital, start-up, operation or maintenance costs.
Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.
There are no anticipated capital start-up cost components or requests to provide information.
Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.
Estimated Costs to the Federal Government:
Processing/Analyzing costs are $8,778,710
VAF 21-0960C-5
(GS-13/5 @ $48.35 x 10,000 x 30/60 minutes = $241,750)
(GS-12/5 @ $40.66 x 10,000 x 30/60 minutes = $203,300)
(GS-9/5 @ $28.04 x 10,000 x 30/60 minutes = $140,200)
Total: $585,250.00
VAF 21-0960C-8
(GS-13/5 @ $48.35 x 15,000 x 15/60 minutes = $181,312.50)
(GS-12/5 @ $40.66 x 15,000 x 15/60 minutes = $152,475.00)
(GS-9/5 @ $28.04 x 15,000 x 15/60 minutes = $105,150.00)
Total: $438,937.50
VAF 21-0960C-9
(GS-13/5 @ $48.35 x 10,000 x 45/60 minutes = $362,625.00)
(GS-12/5 @ $40.66 x 10,000 x 45/60 minutes = $304,950.00)
(GS-9/5 @ $28.04 x 10,000 x 45/60 minutes = $210,300.00)
Total: $877,875.00
VAF 21-0960G-1
(GS-13/5 @ $48.35 x 40,000 x 15/60 minutes = $483,500.00)
(GS-12/5 @ $40.66 x 40,000 x 15/60 minutes = $406,600.00)
(GS-9/5 @ $28.04 x 40,000 x 15/60 minutes = $280,400.00)
Total: $1,170,500.00
VAF 21-0960G-2
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960G-3
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960G-4
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960G-5
(GS-13/5 @ $48.35 x 10,000 x 30/60 minutes = $241,750)
(GS-12/5 @ $40.66 x 10,000 x 30/60 minutes = $203,300)
(GS-9/5 @ $28.04 x 10,000 x 30/60 minutes = $140,200)
Total: $585,250.00
VAF 21-0960G-6
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960G-7
(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875)
(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650)
(GS-9/5 @ $28.04 x 10,000 x 15/60 minutes = $70,100)
Total: $292,625.00
VAF 21-0960G-8
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960H-2
(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875)
(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650)
(GS-9/5 @ $28.04 x 10,000 x 15/60 minutes = $70,100)
Total: $292,625.00
VAF 21-0960K-1
(GS-13/5 @ $48.35 x 30,000 x 15/60 minutes = $362,625)
(GS-12/5 @ $40.66 x 30,000 x 15/60 minutes = $304,950)
(GS-9/5 @ $28.04 x 30,000 x 15/60 minutes = $210,300)
Total: $877,855.00
VAF 21-0960K-2
(GS-13/5 @ $48.35 x 20,000 x 30/60 minutes = $483,500)
(GS-12/5 @ $40.66 x 20,000 x 30/60 minutes = $406,600)
(GS-9/5 @ $28.04 x 20,000 x 30/60 minutes = $280,400)
Total: $1,170,500.00
VAF 21-0960L-2
(GS-13/5 @ $48.35 x 5,000 x 15/60 minutes = $60,437.50)
(GS-12/5 @ $40.66 x 5,000 x 15/60 minutes = $50,825.00)
(GS-9/5 @ $28.04 x 5,000 x 15/60 minutes = $35,050.00)
Total: $146,312.50
VAF 21-0960M-11
(GS-13/5 @ $48.35 x 40,000 x 15/60 minutes = $483,500)
(GS-12/5 @ $40.66 x 40,000 x 15/60 minutes = $406,600)
(GS-9/5 @ $28.04 x 40,000 x 15/60 minutes = $280,400)
Total: $877,855
VAF 21-0960N-1
(GS-13/5 @ $48.35 x 25,000 x 15/60 minutes = $302,187.50)
(GS-12/5 @ $40.66 x 25,000 x 15/60 minutes = $254,125)
(GS-9/5 @ $28.04 x 25,000 x 15/60 minutes = $175,250)
Total: $731,562.50
Printing and production cost $97,541
Total cost to government $8,876,251
Explain the reason for any burden hour changes since the last submission.
There is no change in the reporting burden. This information collection now includes an expiration date placeholder. Also, a comment was received previously during the extension submitted in FY2015. The comments/responses per form listed in the table above in this grouping have resulted in both substantive and non-substantive changes. A supplemental document has been attached to this information collection.
For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.
The information collection is not for publication or tabulation use.
If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
We are not seeking approval to omit the expiration date for OMB approval.
Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.
This submission does not contain any exceptions to the certification statement.
B. Collection of Information Employing Statistical Methods
No statistical methods are used in this data collection.
| 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 | 2021-01-24 |