OMB 2900-0781
VA Form 21-0960C-3 |
Cranial Nerve Conditions Disability Benefits Questionnaire |
VA Form 21-0960C-6 |
Narcolepsy Disability Benefits Questionnaire |
VA Form 21-0960C-7 |
Fibromyalgia Disability Benefits Questionnaire |
VA Form 21-0960C-11 |
Seizure Disorders (Epilepsy) Disability Benefits Questionnaire |
VA Form 21-0960D-1 |
Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire |
VA Form 21-0960E-2 |
Endocrine Diseases (other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire |
VA Form 21-0960E-3 |
Thyroid & Parathyroid Conditions Disability Benefits Questionnaire |
VA Form 21-0960H-1 |
Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire |
VA Form 21-0960I-2 |
HIV-Related Illnesses Disability Benefits Questionnaire |
VA Form 21-0960I-3 |
Infectious Diseases (other than HIV-Related Illness, Chronic Fatigue Syndrome, and Tuberculosis) Disability Benefits Questionnaire |
VA Form 21-0960I-4 |
Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire |
VA Form 21-0960I-5 |
Nutritional Deficiencies Disability Benefits Questionnaire |
VA Form 21-0960J-4 |
Urinary Tract (including Bladder & Urethra) Conditions (excluding Male Reproductive System) Disability Benefits Questionnaire |
VA Form 21-0960L-1 |
Respiratory Conditions (other than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire |
VA Form 21-0960N-3 |
Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire |
VA Form 21-0960N-4 |
Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx, and Pharynx Disability Benefits Questionnaire |
VA Form 21-0960Q-1 |
Chronic Fatigue Syndrome 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 Disability Benefit Questionnaire title will include the name of the specific disability for which it will gather information. VAF 21-0960C-3, Cranial Nerve Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any cranial nerve condition; VAF 21-0960C-6, Narcolepsy Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of narcolepsy; VAF 21-0960C-7, Fibromyalgia Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of fibromyalgia; VAF 21-0960C-11, Seizure Disorders (Epilepsy) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any seizure disorder including epilepsy; VAF 21-0960D-1, Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any oral or dental conditions; VAF 21-0960E-2, Endocrine Diseases (Other Than Thyroid, Parathyroid, or Diabetes Mellitus) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any endocrine disease including cushings and acromegaly however, excluding diabetes; VAF 21-0960E-3, Thyroid & Parathyroid Conditions Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any thyroid or parathyroid condition; VAF 21-0960H-1, Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of abdominal, inguinal, or femoral hernias; VAF 21-0960I-2, HIV-Related Illness Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any HIV-related illness; VAF 21-0960I-3, Infectious Diseases Other Than HIV-Related Illness, Chronic Fatigue Syndrome, and Tuberculosis Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any infectious diseases; VAF 21-0960I-4, Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of lupus or other immune disorders; VAF 21-0960I-5, Nutritional Deficiencies Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of nutritional deficiencies; VAF 21-0960J-4, Urinary Tract ( including Bladder & Urethra) Conditions (excluding Male Reproductive System) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any urinary tract or bladder condition; VAF 21-0960L-1, Respiratory Conditions (Other than Tuberculosis & Sleep Apnea) Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of any respiratory condition; VAF 21-0960N-3, Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire, will gather information related to the claimant’s loss of sense of smell and taste; VAF 21-0960N-4, Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx, and Pharynx Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of sinusitis/rhinitis or other diseases of the nose, throat, larynx, or pharynx; VAF 21-0960Q-1, Chronic Fatigue Syndrome Disability Benefits Questionnaire, will gather information related to the claimant’s diagnosis of chronic fatigue syndrome.
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.
VA Forms 21-0960C-3, 21-0960C-6, 21-0960C-7, 21-0960C-11, 21-0960D-1, 21-0960E-2, 21-0960E-3, 21-0960H-1, 21-0960I-2, 21-0960I-3, 21-0960I-4, 21-0960I-5, 21-0960J-4, 21-0960L-1, 21-0960N-3, 21-0960N-4, and 21-0960Q-1 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.
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 8128 and 8129. Two new comments were received in response to this notice. See Comment 1 and 2, listed below.
Note: These proposed changes are directly associated with receipt of a comment that 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.
Comment 1:
A comment received from Mr. Rick Cullen, stated that VA ratings that are currently in place for disabled veterans are there for a reason, and it's a good one. Veterans that served or are currently serving on active duty may have service-connected disabilities that truly affect their day to day lives. The disability ratings that are in place as of 2016 should remain the same. There shouldn't be any reason why a proposal should be put in place to lower these brave men and women that have served America with honor and dignity. Yes, the VA should always enforce legitimacy as they always have and continue to do. If a veteran is in fact legally disabled and it is service-connected, grant that Vet his or hers disability rating that they deserve. This reform to revise the VASRD is ridiculous and should be reconsidered. More specifically, wanting to lower the current sleep apnea rating of 50% with use of a CPAP should not even be a question. The answer is no! Veterans with sleep apnea are disabled and need s CPAP in order to minimize their symptoms. The CPAP will require lifelong use if a surgery is not conducted. Also that veteran will deal with various symptoms (i.e. Depression) as a secondary condition. All this caused by sleep apnea.
VBA Response to Comment 1:
VA thanks Mr. Cullen for his comment. However, the comment received is unrelated to the proposed changes for DBQs Group 4, since the commenter is referring to the changes in the Veteran Affairs Schedule for Rating Disabilities (VASRD). Thus, no change is warranted.
Comment 2:
A comment was received from Mr. James LaPointe, stating the following:
Are DBQs necessary? According to 38 CFR § 3.326, the answer is no. Any physician statement or report of examination may be used. Since VA will not pay for completion of the form, either the veteran pays or the examiner is not paid for the time needed to complete the form. How many claims have been decided with either evidence meeting the standard at § 3.326 or privately completed DBQs? Have these decisions been completed more timely?
So if § 3.326 evidence or DBQ is not adequate and an examination is required, what happens? VA has made it mandatory that VA examiners use DBQs. But the examiner may use acceptable clinical evidence (ACE) to complete the DBQ. So, the veteran diagnosed with sleep apnea in service submits a physician statement saying a CPAP is required. Rather than grant at 50%, the VA orders an exam and, without seeing the patient, a VA examiner transcribes the treating physician note onto the DBQ noting ACE in lieu of a physical examination. He or she checks the box CPAP required.
VA abandoned the C&P Clinician's Guide around June 28, 2004. Not until VHA Directive 2008-071 (October 29, 2008) did VA authorize VA physicians to make medical statements in support of claims. So what does this have to do with improving the veteran experience in a pro-veteran claims adjudication process where VA has failed to respect § 3.326 for years? Is this about the backlog of claims and more timely decisions? Nope.
When a former VA Secretary awarded a contract for exams to QTC in which he had a financial interest, the game changed significantly. His investment was placed in a blind trust so there was no conflict of interest. Recently VA awarded $6.8 billion dollars to three companies (QTC included) to conduct VA exams. These are the people who need DBQs. Not veterans. Not VA physicians. DBQs are the guide for contract examiners to make money by producing a checkbox exam to meet the requirements of the contract.
So if a veteran with rhinitis brings a note saying he has polyps, will he get his 30% without a contract exam DBQ? Only VA has that data. Better to order an exam to be sure.
If a diabetic loses a foot below the knee, does he need a DBQ to confirm the amputation? How much does QTC charge for an exam to report what VA already knows? VAF 21-0960M-1 allows 30 minutes to determine the absence of a limb. The service connected respiratory condition requiring continuous oxygen? VAF 21-0960L-1 allows 30 minutes.
By VA's own rules, any one of these may be rated upon receipt without additional examination. So why isn't the VA reporting a significant number of ratings completed within days of receipt using private medical evidence?
So, considering the Paperwork Reduction Act, the cost associated with production, revision, notices, etc., and remembering that the VA itself has a rule of evidence saying any report may be used, how can any cost benefit analysis support the scam which has become the kingdom of DBQs? If the only need for DBQs exists in the realm of contract examiners making $6.8 billion, then maybe they should bear the expense of DBQs. Since the VA won't pay the veteran's physician, is it really fair to ask the disabled veteran to pay his own doctor for the time needed to complete an unnecessary form? It seems that such an expense defeats the purpose for which this great nation seeks to compensate those who have served.
VBA Response to Comment 2:
VBA thanks Mr. LaPointe for his comment. VBA would like to respond to his comment in three Parts.
Part I:
VA examinations are a component of VA’s duty to assist. The Veterans Benefits Administration (VBA) requests examinations when the existing evidence of record is not sufficient to rate or make a decision on a claim for benefits. Regarding DBQs as VA examinations, the DBQ is simply the documentation vehicle of either an in-person examination or a comprehensive review of the evidence (Acceptable Clinical Evidence or ACE). VA chose DBQs as the evidence documentation vehicle. Nothing about a DBQ examination request changes VA’s obligation to conduct a full and contemporaneous examination. The only difference is the format of the report sent to VBA.
VA examinations are forensic based vs. treatment based. DBQs are not “necessary” in the context that the writer suggests, but neither are they mandatory for a Veteran to submit with their claim. Simply because a DBQ is not required by a regulation, does not mean that it is not required by something else. The use of a standard examination format is a reflection of VA policy, court decisions, and the need to adhere to the presumption of regularity. By not having a standard examination format, VA would not be able to guarantee that a Veteran receives the same examination regardless of which VA facility provides the examination. Furthermore, VA would not be able to guarantee that we are maximizing the effectiveness of that examination without a standard format that indicates to the examiner exactly what information is needed to evaluate the Veteran. Failure to require DBQs to fulfill VA’s heightened examination duty, once undertaken, would negatively impact the timeliness, accuracy, and consistency of benefits delivery to Veterans.
VA claims adjudication process is non-adversarial and VA has a statutory duty, imposed by Congress, to assist in the development of claims. If a Veteran submits sufficient evidence to rate a claim, the VA will rate the claim. If there is not sufficient evidence to rate a claim, VA has a “duty to assist” which is based in statute and implemented by regulation and numerous court cases. Once VA undertakes the duty to perform an examination under the “duty to assist,” VA’s requirements are heightened and must meet standards that Veteran-submitted evidence does not have to meet (i.e. Mitchell & Deluca) to fulfill the “thorough and contemporaneous examination” requirements implemented through the aforementioned court cases among numerous others. While the evidence Veterans need to submit is technically easier to obtain in terms of standards to meet, not every Veteran is capable of obtaining that evidence nor are they required to do it under the law.
For FY15, less than 28,000 private provider DBQs were submitted by Veterans in support of their claims. During this same period, just under a million VBA 2507 Exam Requests were completed by VHA (Total Exam Templates (DBQs) completed by VHA 2,899,593) and just over 230,000 exams were completed by VBA examination contractors. DBQ’s impact on quality has shown an improvement in examination quality from 85 percent in 2009 to better than 95 percent currently. For the first half of FY16, less than 80,000 ACE examinations were performed. For the same period, over a million VA examinations have been performed.
Part II:
In response to the following statement of, “VA abandoned the C&P Clinician's Guide around June 28, 2004. Not until VHA Directive 2008-071 did VA authorize VA physicians to make medical statements in support of claims,” VHA’s Office of Disability and Medical Assessment provided the following response:
As part of the changing face of the disability program and to ensure quality and timely disability examination process, VA has been transitioning to electronic resources that reflect emerging medical practices and addresses the use of DBQs and incorporates VASRD. This more dynamic approach better meet the needs of examiners and VA, and serves to meet the expectations Veterans’ have for a quality experience during the compensation and pension (C&P) process. VA has numerous references and resources for clinicians who perform C&P disability examinations for Veterans and Service-members. Further, VA continues to update its specialized education and certification program with web-based training modules to assist in conducting these examinations.
Part III:
In response to the following statement of, “VAF 21-0960M-1 allows 30 minutes to determine the absence of a limb. The service connected respiratory condition requiring continuous oxygen? VAF 21-0960L-1 allows 30 minutes,” VBA provided the following response:
The term “burden” means the time, effort, or financial resources, the public expends to provide information to or for a Federal agency, or otherwise fulfill statutory or regulatory requirements. The number of minutes listed on the two forms stated in the comment (i.e. 30 minutes), is the time is takes to complete each form. This amount of time is not the time it takes to diagnose conditions.
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 160,000 per year for all forms:
VAF 21-0960-C-3 – 10,000
VAF 21-0960-C-6 – 5,000
VAF 21-0960-C-7 – 5,000
VAF 21-0960-C-11 – 5,000
VAF 21-0960-D-1 – 5,000
VAF 21-0960-E-2 – 10,000
VAF 21-0960-E-3 – 10,000
VAF 21-0960-H-1 – 15,000
VAF 21-0960-I-2 – 5,000
VAF 21-0960-I-3 – 10,000
VAF 21-0960-I-4 – 5,000
VAF 21-0960-I-5 – 5,000
VAF 21-0960-J-4 – 15,000
VAF 21-0960-L-1 – 20,000
VAF 21-0960-N-3 – 5,000
VAF 21-0960-N-4 – 20,000
VAF 21-0960-Q-1 – 10,000
The estimated completion time for each form is as follows:
VAF 21-0960C-3 – 30 minutes
VAF 21-0960C-6 – 15 minutes
VAF 21-0960C-7 – 15 minutes
VAF 21-0960C-11 – 15 minutes
VAF 21-0960D-1 – 15 minutes
VAF 21-0960E-2 – 15 minutes
VAF 21-0960E-3 – 15 minutes
VAF 21-0960H-1 – 15 minutes
VAF 21-0960I-2 – 15 minutes
VAF 21-0960I-3 – 15 minutes
VAF 21-0960I-4 – 30 minutes
VAF 21-0960I-5 – 15 minutes
VAF 21-0960J-4 – 15 minutes
VAF 21-0960L-1 – 30 minutes
VAF 21-0960N-3 – 15 minutes
VAF 21-0960N-4 – 30 minutes
VAF 21-0960Q-1 – 15 minutes
Annual burden hours is estimated at 53,750 burden hours:
VAF 21-0960C-3 – 5,000
VAF 21-0960C-6 – 1,250
VAF 21-0960C-7 – 1,250
VAF 21-0960C-11 – 1,250
VAF 21-0960D-1 – 1,250
VAF 21-0960E-2 – 2,500
VAF 21-0960E-3 – 2,500
VAF 21-0960H-1 – 3,750
VAF 21-0960I-2 – 1,250
VAF 21-0960I-3 – 2,500
VAF 21-0960I-4 – 2,500
VAF 21-0960I-5 – 1,250
VAF 21-0960J-4 – 3,750
VAF 21-0960L-1 – 10,000
VAF 21-0960N-3 – 1,250
VAF 21-0960N-4 – 10,000
VAF 21-0960Q-1 – 2,500
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 $1,087,363.00 (53,750 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 $6,007,924.50
VAF 21-0960-C-3
(GS-13/5 @ $48.35 x 10,000 x 30/60 minutes = $241,750.00) (GS-12/5 @ $40.66 x 10,000 x 30/60 minutes = $203,300.00)
(GS- 9/5 @ $28.04 x 10,000 x 30/60 minutes = $140,200.00)
Total: $585,250.00
VAF 21-0960-C-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 21-0960-C-7
(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 21-0960-C-11
(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 21-0960-D-1
(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 21-0960-E-2
(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875.00)
(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650.00)
(GS- 9/5 @ $28.04 x 10,000 x 15/60 minutes = $ 70,100.00)
Total: $292,625.00
VAF 21-0960-E-3
(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875.00)
(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650.00)
(GS- 9/5 @ $28.04 x 10,000 x 15/60 minutes = $ 70,100.00)
Total: $292,625.00
VAF 21-0960-H-1
(GS-13/5 @ $48.35 x 15,000 x 15/60 minutes = $181,312)
(GS-12/5 @ $40.66 x 15,000 x 15/60 minutes = $152,475)
(GS- 9/5 @ $28.04 x 15,000 x 15/60 minutes = $105,150)
Total: $438,937.00
VAF 21-0960-I -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 21-0960-I-3
(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875.00)
(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650.00)
(GS- 9/5 @ $28.04 x 10,000 x 15/60 minutes = $ 70,100.00)
Total: $292,625.00
VAF 21-0960-I-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 21-0960-I-5
(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 21-0960-J-4
(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: $301,737.50
VAF 21-0960-L-1
(GS-13/5 @ $48.35 x 20,000 x 30/60 minutes = $483,500.00)
(GS-12/5 @ $40.66 x 20,000 x 30/60 minutes = $406,600.00)
(GS- 9/5 @ $28.04 x 20,000 x 30/60 minutes = $280,400.00)
Total: $1,170,500.00
VAF 21-0960-N-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 21-0960-N-4
(GS-13/5 @ $48.35 x 20,000 x 30/60 minutes = $483,500.00)
(GS-12/5 @ $40.66 x 20,000 x 30/60 minutes = $406,600.00)
(GS- 9/5 @ $28.04 x 20,000 x 30/60 minutes = $280,400.00)
Total: $1,170,500.00
VAF 21-0960-Q-1
(GS-13/5 @ $48.35 x 10,000 x 15/60 minutes = $120,875.00)
(GS-12/5 @ $40.66 x 10,000 x 15/60 minutes = $101,650.00)
(GS- 9/5 @ $28.04 x 10,000 x 15/60 minutes = $ 70,100.00)
Total: $292,625.00
Printing and production cost $66,755
Total cost to government $6,074,680.50
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 |