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

ICR 202009-2900-010

OMB: 2900-0065

Federal Form Document

ICR Details
2900-0065 202009-2900-010
Received in OIRA 201612-2900-016
VA VBA-COMP-YA
Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)
Reinstatement with change of a previously approved collection   No
Regular 05/20/2021
  Requested Previously Approved
36 Months From Approved
25,250 0
6,313 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. Without this information, determination of entitlement would not be possible. No changes have been made to this form. The decrease in respondent burden is due to the estimated number of receivables from the previous year.

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

Not associated with rulemaking

  86 FR 13791 03/10/2021
86 FR 26782 05/17/2021
No

  Total Request 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 25,250 0 0 -34,750 0 60,000
Annual Time Burden (Hours) 6,313 0 0 -8,687 0 15,000
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
The respondent burden has decreased due to the estimated number of receivables averaged over the past year.

$467,336
No
    Yes
    Yes
No
No
No
No
Maribel Aponte 202 266-4688 maribel.aponte@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.
05/20/2021


© 2024 OMB.report | Privacy Policy