OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Statement in Support of Claim for Disability and Related Compensation Benefits Due to Exposure (21-0964)

ICR 201404-2900-006 · OMB 2900-0827 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 21-0964 Statement in Support of Claim for Disability and Related Compensation Benefits Due to Exposure (21-0964) Form New Available
Comment VA-2014-VACO-0001-0108.docx Supporting Statement B Uploaded 2014-06-11 Available
New VA ICR-Exposure Form # 201404-2900-006 (12-23-14 clean copy).docx Supporting Statement A Uploaded 2014-12-30 Available
IC Document Collections
IC IDCollectionTypeStatusForm
211174 Statement in Support of Claim for Disability and Related Compensation Benefits Due to Exposure (21-0964) Form New
ICR Details
2900-0827 201404-2900-006
Historical Active
VA 2900-NEW VBA-COMP-YM
Statement in Support of Claim for Disability and Related Compensation Benefits Due to Exposure (21-0964)
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 01/02/2015
Retrieve Notice of Action (NOA) 07/08/2014
  Inventory as of this Action Requested Previously Approved
01/31/2018 36 Months From Approved
20,000 0 0
6,667 0 0
0 0 0
VA Form 21-0964, Statement in Support of Claim for Disability and Related Compensation Benefits Due to Exposure, is a 'new' collection, used to gather information related to exposure. Without this data collection, determination of entitlement due to exposure, would not be possible.
US Code: 38 USC 5101(a) Name of Law: Claims and Forms
  
None
Not associated with rulemaking
  79 FR 73 04/16/2014
79 FR 123 06/26/2014
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 20,000 0 0 20,000 0 0
Annual Time Burden (Hours) 6,667 0 0 6,667 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This form is new. The burden reported is due to a new data collection request.
$152,000
No
No
No
No
No
Uncollected
Crystal Rennie 202 632-7492 [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.
07/08/2014