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Federal forms, ICRs, and supporting documents

Information Collection Request

REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS

ICR 199007-2900-003 · OMB 2900-0065 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
146835 REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS Form Migrated
ICR Details
2900-0065 199007-2900-003
Historical Active 198904-2900-021
VA
REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS
Extension without change of a currently approved collection   No
Regular
Approved without change 09/06/1990
Retrieve Notice of Action (NOA) 07/13/1990
  Inventory as of this Action Requested Previously Approved
07/31/1993 07/31/1993 07/31/1990
65,000 0 65,000
16,250 0 16,250
0 0 0
VA FORM 21-4192 IS USED TO DETERMINE THE VETERAN'S ABILITY TO WORK, OR INABILITY TO WORK, BASED ON A REPORT FROM HIS/HER LAST EMPLOYER. THE FORM IS SENT TO THE LAST EMPLOYER, WITH INSTRUCTIONS FOR ITS COMPLETIO AND DIRECT RETURN TO A VA REGIONAL OFFICE.
None
None
No
1
IC Title Form No. Form Name
REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS 21-4192
  Total Approved 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 65,000 65,000 0 0 0 0
Annual Time Burden (Hours) 16,250 16,250 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  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.
07/13/1990