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

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

OMB: 2900-0065

IC ID: 28204

Documents and Forms
Document Name
Document Type
Form
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) 2900-0065
 
No Modified
 
Voluntary
 
38 CFR 3.341 38 CFR 3.340 38 CFR 3.342

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits VBA-21-4192-ARE 4-25-24.pdf www.va.gov/vaforms Yes No Fillable Printable

General Government Legislative Functions

Compensation, Pension, Education, and Veteran Readiness and Employment Records-VA (58VA21/22/28)  87 FR 8740

48,730 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 48,730 0 23,480 0 0 25,250
Annual IC Time Burden (Hours) 12,183 0 5,870 0 0 6,313
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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