OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Request for Employment Information in Connection with Claim for Disability Benefits

ICR 201009-2900-020 · OMB 2900-0065 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits Form Modified Repair queued
2900-0065 justification.docx Supporting Statement A Uploaded 2010-12-16 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28204 Request for Employment Information in Connection with Claim for Disability Benefits Form Modified
ICR Details
2900-0065 201009-2900-020
Historical Active 200707-2900-015
VA 2900-0065
Request for Employment Information in Connection with Claim for Disability Benefits
Extension without change of a currently approved collection   No
Regular
Approved without change 02/27/2011
Retrieve Notice of Action (NOA) 12/23/2010
  Inventory as of this Action Requested Previously Approved
02/28/2014 36 Months From Approved 02/28/2011
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
  
None
Not associated with rulemaking
  75 FR 191 10/04/2010
75 FR 239 12/14/2010
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 60,000 60,000 0 0 0 0
Annual Time Burden (Hours) 15,000 15,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$4,037,010
No
No
No
No
No
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.
12/23/2010