Disability Benefits Questionnaires (21-0960A-1, 21-0960B-1, 21-0960C-1)

ICR 201610-2900-005

OMB: 2900-0749

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supplementary Document
2017-02-10
Supplementary Document
2016-12-02
Supporting Statement A
2017-02-10
IC Document Collections
IC ID
Document
Title
Status
193056 Modified
ICR Details
2900-0749 201610-2900-005
Historical Active 201305-2900-001
VA VBA-COMP-DJ
Disability Benefits Questionnaires (21-0960A-1, 21-0960B-1, 21-0960C-1)
Extension without change of a currently approved collection   No
Regular
Approved without change 06/13/2017
Retrieve Notice of Action (NOA) 02/16/2017
  Inventory as of this Action Requested Previously Approved
06/30/2020 36 Months From Approved 06/30/2017
62,000 0 62,000
15,500 0 15,500
0 0 0

VA Form 21-0960 series is used to gather necessary information from a claimant’s treating physician regarding the results of medical examinations.

US Code: 38 USC 501a Name of Law: Veterans Benefits
  
None

Not associated with rulemaking

  81 FR 80720 11/16/2016
82 FR 8563 01/26/2017
No

1
IC Title Form No. Form Name
Disability Benefits Questionnaires VA Form 21-0960A-1, VA Form 21-0960B-1, VA Form 21-0960C-1 Ischemic Heart Disease (IHD) Disability Benefits Questionnaire ,   Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire ,   Parkinson's Disease Disability Benefits Questionnaire

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 62,000 62,000 0 0 0 0
Annual Time Burden (Hours) 15,500 15,500 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$5,399,394
No
No
No
No
No
Uncollected
Cynthia Harvey - Pryor 202 461-5870 cynthia.harvey-pryor@va.gov

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
02/16/2017


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