OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident

ICR 200805-2900-008 · OMB 2900-0104 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 21-4176 Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident Form Modified Available
OMB21-4176(11-24-08).doc Supporting Statement A Uploaded 2008-11-24 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28285 Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident Form Modified
ICR Details
2900-0104 200805-2900-008
Historical Active 200603-2900-003
VA 2900-0104
Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident
Extension without change of a currently approved collection   No
Regular
Approved without change 01/08/2009
Retrieve Notice of Action (NOA) 11/25/2008
  Inventory as of this Action Requested Previously Approved
01/31/2012 36 Months From Approved 04/30/2009
4,408 0 4,408
2,204 0 2,204
0 0 0
VA Form 21-4176 is used to gather information that is necessary to determine eligibility for compensation or pension benefits based on disability which is the result of an accident. Benefits are not payable where an injury is the result of willful misconduct. Without this information, VA would be unable to properly authorize benefits.
US Code: 38 USC 1110 Name of Law: Basic entitlement
   US Code: 38 USC 1131 Name of Law: Basic entitlement
   US Code: 38 USC 1521 Name of Law: Veterans of a period of war
   US Code: 38 USC 105 Name of Law: Line of duty and misconduct
  
None
Not associated with rulemaking
  73 FR 107 06/03/2008
73 FR 167 08/27/2008
No
  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 4,408 4,408 0 0 0 0
Annual Time Burden (Hours) 2,204 2,204 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$97,632
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Denise McLamb 202-565-8374 [email protected]
  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.
11/25/2008