Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)

ICR 201612-2900-016

OMB: 2900-0065

Federal Form Document

IC Document Collections
ICR Details
2900-0065 201612-2900-016
Historical Active 201405-2900-008
VA VBA-COMP-YA
Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)
Extension without change of a currently approved collection   No
Regular
Approved with change 09/14/2017
Retrieve Notice of Action (NOA) 06/08/2017
  Inventory as of this Action Requested Previously Approved
09/30/2020 36 Months From Approved 11/30/2017
60,000 0 60,000
15,000 0 15,000
0 0 0

VA Form 21-4192 is used to gather necessary employment information from Veterans' employers so VA can determine eligibility to increased disability benefits based on unemployability.

US Code: 38 USC 1502 Name of Law: Determinations with Respect to Disability
  
None

Not associated with rulemaking

  82 FR 6729 01/19/2017
82 FR 20686 05/03/2017
No

  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 60,000 60,000 0 0 0 0
Annual Time Burden (Hours) 15,000 15,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$2,578,333
No
    Yes
    Yes
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.
06/08/2017


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