Information Collection

Disability Benefits Questionnaires (Group 4)

IC 196008 under ICR 201511-2900-002 · OMB 2900-0781.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0781 can be found here:

2019-10-01 - Extension without change of a currently approved collection

Documents and Forms

Document Name Document Type
Form VA Form 21-0960C-3 Disability Benefits Questionnaires (Group 4) Form
VA Form 21-0960C-3 Cranial Nerves Diseases Disability Benefits Questionnair 21-0960C-3(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960C-6 Narcolepsy Disability Benefits Questionnaire 21-0960C-6(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960C-7 Fibromyalgia Disability Benefits Questionnaire 21-0960C-7(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960C-1 Seizure Disorders (Epilepsy) Disability Benefits Questio 21-0960C-11(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960D-1 Oral and Dental Conditions Including Mouth, Lips and Ton 21-0960D-1(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960E-2 Endocrine Diseases (Other than Thyroid, Parathyroid or D 21-0960E-2(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960E-3 Thyroid and Parathyroid Conditions Disability Benefits Q 21-0960E-3(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960H-1 Hernias (Including Abdominal, Inguinal and Femoral Herni 21-0960H-1(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960I-2 HIV - Related Illnesses Disability Benefits Questionnair 21-0960I-2(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960I-3 Infectious Diseases (Other than HIV-Related Illness, Chr 21-0960I-3(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960I-4 Systemic Lupus Erythematosus (SLE) and Other Autoimmune 21-0960I-4(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960I-5 Nutritional Deficiencies Disability Benefits Questionnai 21-0960I-5(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960J-4 Urinary Tract (Including Bladder and Urethra) Conditions 21-0960J-4(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960L-1 Respiratory Conditions (Other than Tuberculosis and Slee 21-0960L-1(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960N-3 Loss of Sense of Smell and/or Taste Disability Benefits 21-0960N-3(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960N-4 Sinusitis/Rhinitis and Other Conditions of the Nose, Thr 21-0960N-4(1-21-16).pdf www.va.gov/vaforms Form
VA Form 21-0960Q-1 Chronic Fatigue Syndrome Disability Benefits Questionnai 21-0960Q-1(1-21-16).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Disability Benefits Questionnaires (Group 4)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-0960C-3	Cranial Nerves Diseases Disability Benefits Questionnaire	21-0960C-3(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-6	Narcolepsy Disability Benefits Questionnaire	21-0960C-6(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-7	Fibromyalgia Disability Benefits Questionnaire	21-0960C-7(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960C-11	Seizure Disorders (Epilepsy) Disability Benefits Questionnaire	21-0960C-11(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960D-1	Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire	21-0960D-1(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960E-2	Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire	21-0960E-2(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960E-3	Thyroid and Parathyroid Conditions Disability Benefits Questionnaire	21-0960E-3(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960H-1	Hernias (Including Abdominal, Inguinal and Femoral Hernias) Disability Benefits Questionnaire	21-0960H-1(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-2	HIV - Related Illnesses Disability Benefits Questionnaire	21-0960I-2(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-3	Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire	21-0960I-3(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-4	Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire	21-0960I-4(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960I-5	Nutritional Deficiencies Disability Benefits Questionnaire	21-0960I-5(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960J-4	Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire	21-0960J-4(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960L-1	Respiratory Conditions (Other than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire	21-0960L-1(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960N-3	Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire	21-0960N-3(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960N-4	Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire	21-0960N-4(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	VA Form 21-0960Q-1	Chronic Fatigue Syndrome Disability Benefits Questionnaire	21-0960Q-1(1-21-16).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 160,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	160,000	160,000
Annual IC Time Burden (Hours)	53,750	53,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.