Document Name Document Type
Form VA Form 21-0960C-5 Disability Benefits Questionnaires (Group 3) Form
VA Form 21-0960C-5 CENTRAL NERVOUS SYSTEM AND NEUROMUSCULAR DISEASES VA Form 21-0960C-5 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960C-8 HEADACHES (INCLUDING MIGRAINE HEADACHES) VA Form 21-0960C-8 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960C-9 MULTIPLE SCLEROSIS (MS) VA Form 21-0960C-9 (1-13-16).pdf www.va.gov/vafaorms Form
VA Form 21-0960-G- ESOPHAGEAL CONDITIONS (Including gastroesophageal reflux VA Form 21-0960G-1 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960G-2 GALLBLADDER AND PANCREAS CONDITIONS VA Form 21-0960G-2 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960G-3 INTESTINAL CONDITIONS (OTHER THAN SURGICAL OR INFECTIOUS VA Form 21-0960G-3 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960G-4 INTESTINAL SURGERY (BOWEL RESECTION, COLOSTOMY, ILEOSTOM VA Form 21-0960G-4 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960G-5 HEPATITIS, CIRRHOSIS AND OTHER LIVER CONDITIONS VA Form 21-0960G-5 (1-12-16).pdf www.va.gov/vaforms Form
VA Form 21-0960G-6 PERITONEAL ADHESIONS DISABILITY BENEFITS QUESTIONNAIRE VA Form 21-0960G-6 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960G-7 STOMACH AND DUODENAL CONDITIONS (NOT INCLUDING GERD OR E VA Form 21-0960G-7 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960G-8 INFECTIOUS INTESTINAL DISORDERS, INCLUDING BACTERIAL AND VA Form 21-0960G-8 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960H-2 RECTUM AND ANUS CONDITIONS (INCLUDING HEMORRHOIDS) DISAB VA Form 21-0960H-2 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960K-1 BREAST CONDITIONS AND DISORDERS DISABILITY BENEFITS QUES VA Form 21-0960K-1 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960K-2 GYNECOLOGICAL CONDITIONS DISABILITY BENEFITS QUESTIONNAI VA Form 21-0960K-2 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960L-2 SLEEP APNEA DISABILITY BENEFITS QUESTIONNAIRE VA Form 21-0960L-2 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960M-1 OSTEOMYELITIS DISABILITY BENEFITS QUESTIONNAIRE VA Form 21-0960M-11 (1-13-16).pdf www.va.gov/vaforms Form
VA Form 21-0960N-1 EAR CONDITIONS (INCLUDING VESTIBULAR AND INFECTIOUS COND VA Form 21-0960N-1 (1-13-16).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

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IC Title:	Disability Benefits Questionnaires (Group 3)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-0960C-5	CENTRAL NERVOUS SYSTEM AND NEUROMUSCULAR DISEASES	VA Form 21-0960C-5 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-8	HEADACHES (INCLUDING MIGRAINE HEADACHES)	VA Form 21-0960C-8 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-9	MULTIPLE SCLEROSIS (MS)	VA Form 21-0960C-9 (1-13-16).pdf	www.va.gov/vafaorms	Yes	No	Fillable Printable
Form	VA Form 21-0960-G-1	ESOPHAGEAL CONDITIONS (Including gastroesophageal reflux disease (GERD),	VA Form 21-0960G-1 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-2	GALLBLADDER AND PANCREAS CONDITIONS	VA Form 21-0960G-2 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-3	INTESTINAL CONDITIONS (OTHER THAN SURGICAL OR INFECTIOUS)	VA Form 21-0960G-3 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-4	INTESTINAL SURGERY (BOWEL RESECTION, COLOSTOMY, ILEOSTOMY) DISABILITY BENEFITS QUESTIONNAIRE	VA Form 21-0960G-4 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-5	HEPATITIS, CIRRHOSIS AND OTHER LIVER CONDITIONS	VA Form 21-0960G-5 (1-12-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-6	PERITONEAL ADHESIONS DISABILITY BENEFITS QUESTIONNAIRE	VA Form 21-0960G-6 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-7	STOMACH AND DUODENAL CONDITIONS (NOT INCLUDING GERD OR ESOPHAGEAL DISORDERS) DISABILITY BENEFITS QUESTIONNAIRE	VA Form 21-0960G-7 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960G-8	INFECTIOUS INTESTINAL DISORDERS, INCLUDING BACTERIAL AND	VA Form 21-0960G-8 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960H-2	RECTUM AND ANUS CONDITIONS (INCLUDING HEMORRHOIDS) DISABILITY BENEFITS QUESTIONNAIRE	VA Form 21-0960H-2 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960K-1	BREAST CONDITIONS AND DISORDERS DISABILITY BENEFITS QUESTIONNAIRE	VA Form 21-0960K-1 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960K-2	GYNECOLOGICAL CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE	VA Form 21-0960K-2 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960L-2	SLEEP APNEA DISABILITY BENEFITS QUESTIONNAIRE	VA Form 21-0960L-2 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960M-11	OSTEOMYELITIS DISABILITY BENEFITS QUESTIONNAIRE	VA Form 21-0960M-11 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960N-1	EAR CONDITIONS (INCLUDING VESTIBULAR AND INFECTIOUS CONDITIONS) DISABILITY BENEFITS QUESTIONNAIRE	VA Form 21-0960N-1 (1-13-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title: Compensation, Pension, Education, and Rehabilitation RecordsVA (58VA21/22/28)	FR Citation: 74 FR 117

Number of Respondents: 250,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	250,000	250,000
Annual IC Time Burden (Hours)	77,500	77,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Disability Benefits Questionnaires (Group 3)

Disability Benefits Questionnaires (Group 3)

OMB: 2900-0778

IC ID: 196002

View Information Collection (IC)