Neck (Cervical Spine) Conditions Disability Benefits Questionnaire (VA Form 21-0960M-13)

ICR 201711-2900-011

OMB: 2900-0807

Federal Form Document

IC Document Collections
ICR Details
2900-0807 201711-2900-011
Historical Active 201304-2900-030
VA VBA-COMP-DJ
Neck (Cervical Spine) Conditions Disability Benefits Questionnaire (VA Form 21-0960M-13)
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 03/05/2018
Retrieve Notice of Action (NOA) 11/20/2017
  Inventory as of this Action Requested Previously Approved
03/31/2021 36 Months From Approved
50,000 0 0
37,500 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. VA Form 21-0960M-13 is being revised to include new standardization data points; to include optical character recognition boxes. This is a non-substantive change.

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

Not associated with rulemaking

  82 FR 12703 03/06/2017
82 FR 38760 08/15/2017
Yes

  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 50,000 0 0 0 0 50,000
Annual Time Burden (Hours) 37,500 0 0 0 0 37,500
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$4,398,333
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.
11/20/2017


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