Request for Employment Information in Connection with Claim for Disability Benefits

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0065 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits Form
VA Form 21-4192 REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CL VA Form 21-4192 (11-30-16).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

IC Title:	Request for Employment Information in Connection with Claim for Disability Benefits	Agency IC Tracking Number:	2900-0065 VBA-COMP-YM

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 3.342 38 CFR 3.340 38 CFR 3.341

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-4192	REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS	VA Form 21-4192 (11-30-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	60,000	60,000
Annual IC Time Burden (Hours)	15,000	15,000
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.