Employment Questionnaire (VA Form 21-4140)

Forms and Documents

Document Name	Status
Form 21-4140 Employment Questionnaire (VA Form 21-4140) Form	Modified
2021-10298, 30-Day FRN (2900-0079).pdf Supplementary Document	2021-05-20
2021-05048, 60-Day FRN (2900-0079).pdf Supplementary Document	2021-03-11
2900-0079, Supporting Statement (VAF21-4140).docx Supporting Statement A	2021-05-05

IC Document Collections

IC ID	Document Title	Status
28229	Employment Questionnaire (VA Form 21-4140) Form	Modified

ICR Details

OMB Control No: 2900-0079	ICR Reference No: 202009-2900-012
Status: Received in OIRA	Previous ICR Reference No: 201702-2900-003
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-YA
Title: Employment Questionnaire (VA Form 21-4140)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 05/24/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	2,960	0
Time Burden (Hours)	247	0
Cost Burden (Dollars)	0	0

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Abstract: VA Forms 21-4140 is used to gather the necessary information to determine continued entitlement to individual unemployability. 38 CFR 3.652 provides that recipients are required to certify, when requested, that the eligibility factors which established entitlement to the benefit being paid continue to exist. Individual unemployability is awarded based on a veteran’s inability to be gainfully employed due to service-connected disabilities, and entitlement may be terminated if a veteran begins working. Without information about recipients’ employment, VA would not be able to determine continued entitlement to individual unemployability, and overpayments would result. The respondent burden has decreased due to the removal of one of the forms listed within this collection. This collection used to include; • VA Form 21-4140, and • VA Form 21-4140-1. VA Form 21-4140 was only available as a computer -generated form which was dispatched as a monthly batch print through VA’s central computer system. VA Form 21-4140-1 was available on the One-VA website, for the usability of the claimant should they not receive the batch printed form. However, the batch print for VA Form 21-4140 is no longer in use. Thus, the two forms were combined into one form number, called VA Form 21-4140. This collection will now be associated with the one form number. No changes have been made to VA Form 21-4140.

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Authorizing Statute(s): US Code: 38 USC 5317 Name of Law: Use of income information from other agencies: notice and verification
   US Code: 38 USC 501 Name of Law: Rules and regulations
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 13969	03/11/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 26783	05/17/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Employment Questionnaire (VA Form 21-4140)	21-4140	Employment Questionnaire

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ICR Summary of Burden

	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	2,960	0	0	-127,040	0	130,000
Annual Time Burden (Hours)	247	0	0	-10,586	0	10,833
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The respondent burden has decreased due to the removal of one of the forms listed within this collection.

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Annual Cost to Federal Government: $57,608

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 05/24/2021

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