Decision Review Request: Supplemental Claim (VA Form 20-0995)

Forms and Documents

Document Name	Status
Form 20-0995 Decision Review Request: Supplemental Claim (VA Form 20-0995) Form	New
OMB-30-Day FR Notice - 0995.pdf Supplementary Document	2021-02-22
60-Day FRN - 2900-NEW (VA Form 20-0995) 2020.pdf Supplementary Document	2020-12-14
2900-NEW Supporting Statement 20-0995_FEB2021.docx Supporting Statement A	2021-02-10

IC Document Collections

IC ID	Document Title	Status
244441	Decision Review Request: Supplemental Claim (VA Form 20-0995) Form	New

ICR Details

OMB Control No:	ICR Reference No: 202011-2900-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: VBA-OAR-YA
Title: Decision Review Request: Supplemental Claim (VA Form 20-0995)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/25/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	265,000	0
Time Burden (Hours)	66,250	0
Cost Burden (Dollars)	0	0

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Abstract: VA Form 20-0995, Decision Review Request: Supplemental Claim, will be used by a claimant and/or beneficiary to formally request a review of an initial VA decision, based on new and relevant evidence, in accordance with the Appeals Modernization Act. The information collected will be used by VA to identify the issues in dispute which the claimant seeks review of in the Supplemental Claim Lane.

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Authorizing Statute(s): PL: Pub.L. 115 - 55 2 Name of Law: Veterans Appeals Improvement and Modernization Act of 2017
   US Code: 38 USC 5108 Name of Law: Supplemental Claims
  

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:
	85 FR 80895	12/14/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 10168	02/18/2021
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
Decision Review Request: Supplemental Claim (VA Form 20-0995)	20-0995	DECISION REVIEW REQUEST: SUPPLEMENTAL CLAIM

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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	265,000	0	0	265,000	0	0
Annual Time Burden (Hours)	66,250	0	0	66,250	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This form used to be a part of collection #2900-0862. This is a request for a new OMB control number.

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Annual Cost to Federal Government: $15,288,910

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: 02/25/2021

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