Approved consistent with the following terms of clearance, in the next submission of this clearance to OMB for review VA shall report on Dept. efforts to provide a fully electronic version of associated forms to respondents.
Inventory as of this Action
Requested
Previously Approved
01/31/2011
36 Months From Approved
12/31/2007
60,000
0
60,000
15,000
0
15,000
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.
US Code:
38 USC 1502
Name of Law: Determinations with Respect to Disability
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.
Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits
OMB21-4192(11-9-07).doc
Request for Employment Information in Connection with Claim for Disability Benefits