Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)

ICR 201612-2900-004

OMB: 2900-0802

Federal Form Document

IC Document Collections
ICR Details
2900-0802 201612-2900-004
Historical Inactive 201304-2900-029
VA VBA-COMP-DJ
Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)
Reinstatement with change of a previously approved collection   Yes
Regular
Withdrawn and continue 09/29/2017
Retrieve Notice of Action (NOA) 05/11/2017
VA withdraws this collection to make a technical correction to the way it was submitted.
  Inventory as of this Action Requested Previously Approved
04/30/2017 36 Months From Approved
50,000 0 0
25,000 0 0
0 0 0

The form 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.

US Code: 38 USC 501(a) Name of Law: Rules and Regulations
  
None

Not associated with rulemaking

  82 FR 8568 01/26/2017
82 FR 18537 04/19/2017
No

1
IC Title Form No. Form Name
Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12) VA Form 21-0960M-12 Shoulder and Arm Conditions Disability Benefits Questionnaire

No
No

$4,398,333
No
No
No
No
No
Uncollected
Cynthia Harvey - Pryor 202 461-5870 cynthia.harvey-pryor@va.gov

  Yes
 
Agency/Sub Agency RCF ID RCF Title RCF Status IC Title

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.
05/11/2017


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