Disability Benefits Questionnaires (Group I )

Disability Benefits Questionnaires (Group 1)

OMB: 2900-0779

IC ID: 195776

Documents and Forms

Document Name Document Type
Form VA Form 21-0960B-2 Disability Benefits Questionnaires (Group I ) Form
VA Form 21-0960B-2 Hematologic and Lymphatic Conditions, Including Leukemia VAF 21-0960B-2.pdf www.va.gov/vaforms Form
VA Form 21-0960J-2 Male Reproductive Organ Conditions Disability Benefits Q VAV 21-0960J-2.pdf www.va.gov/vaforms Form
VA Form 21-0960I-1 Persian Gulf and Afghanistan Infectious Diseases Disabil VAF 21-0960I-1.pdf www.va.gov/vaforms Form
VA Form 21-0960I-6 Tuberculosis Disability Benefits Questionnaire VAF 21-0960I-6.pdf www.va.gov/vaforms Form
VA Form 21-0960C-2 Amotrophic Lateral Sclerosis (Lou Gehrig's Disease) Disa VAF 21-0960C-2.pdf www.va.gov/vaforms Form
VA Form 21-0960C-1 Peripheral Nerves Conditions (Not Including Diabetic Sen VAF 21-0960C-10.pdf www.va.gov/vaforms Form
VA Form 21-0960J-1 Kidney Conditions (Nephrology) Disability Benefits Quesi VAF 21-0960J-1.pdf www.va.gov/vaforms Form
VA Form 21-0960P-1 Eating Disorders Disability Benefits Quesitonnaire VAF 21-0960P-1.pdf www.va.gov/vaforms Form
VA Form 21-0960P-2 Mental Disorders (Other than PTSD and Eating Disorders) VAF 21-0960P-2.pdf www.va.gov/vaforms Form
VA Form 21-0960P-3 Review Post Traumatic Stress Disorder (PTSD) Disability VAF 21-0960P-3.pdf www.va.gov/vaforms Form
VA Form 21-0960J-3 Prostate Cancer Disability Benefits Questionnaire VAF 21-0960J-3.pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Disability Benefits Questionnaires (Group I )	Agency IC Tracking Number:	VBA-COMP-DJ&YA

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.351 38 CFR 3.326

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-0960B-2	Hematologic and Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire	VAF 21-0960B-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960J-2	Male Reproductive Organ Conditions Disability Benefits Questionnaire	VAV 21-0960J-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-1	Persian Gulf and Afghanistan Infectious Diseases Disability Benefits Questionnaire	VAF 21-0960I-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-6	Tuberculosis Disability Benefits Questionnaire	VAF 21-0960I-6.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-2	Amotrophic Lateral Sclerosis (Lou Gehrig's Disease) Disability Benefits Questionnaire	VAF 21-0960C-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-10	Peripheral Nerves Conditions (Not Including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire	VAF 21-0960C-10.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960J-1	Kidney Conditions (Nephrology) Disability Benefits Quesionnaire	VAF 21-0960J-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960P-1	Eating Disorders Disability Benefits Quesitonnaire	VAF 21-0960P-1.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960P-2	Mental Disorders (Other than PTSD and Eating Disorders) Disability Benefits Questionnaire	VAF 21-0960P-2.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960P-3	Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire	VAF 21-0960P-3.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960J-3	Prostate Cancer Disability Benefits Questionnaire	VAF 21-0960J-3.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title: Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28)	FR Citation: 75 FR 80

Number of Respondents: 307,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	307,000	0	0	307,000
Annual IC Time Burden (Hours)	127,917	0	0	127,917
Annual IC Cost Burden (Dollars)	3,070,008	-3,052,099	3,052,099	3,070,008

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.