OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Statement in Support of Claim for Service Connection for PTSD (21-0781), Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault (21-0781a)

ICR 201610-2900-003 · OMB 2900-0659 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 21-0781a Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder Secondary to Personal Assault Form Modified Repair queued
Form 21-0781 Statement in Support of Claim for Service Connection for Post Traumatic Stress Disorder (PTSD) Form Modified Repair queued
Supporting Statement for 2900-0659 (VAF 0781 and 0781a) 03-23-17.docx Supporting Statement A Uploaded 2017-03-23 Available
2900-0659 30-day FRN published 03-7-17.pdf Supplementary Document Uploaded 2017-03-14 Repair queued
2900-0659 Comments & Responses (Supplemental Document).docx Public Comments Uploaded 2017-02-13 Repair queued
2900-0659_VFW_Public_Submission.pdf Public Comments Uploaded 2017-02-13 Repair queued
2900-0659_VFW_Public_Comment.pdf Public Comments Uploaded 2017-02-13 Repair queued
60-FRN (OMB 2900-0659) Published_12_15_2016.pdf Supplementary Document Uploaded 2016-12-15 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
28937 Statement in Support of Claim for Service Connection for PTSD (21-0781), Statement in Support of Claim for Service Connection for PTSD(VA Form 21-0781a) Form ModifiedStatement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder Secondary to Personal Assault
28937 Statement in Support of Claim for Service Connection for PTSD (21-0781), Statement in Support of Claim for Service Connection for PTSD(VA Form 21-0781a) Form ModifiedStatement in Support of Claim for Service Connection for Post Traumatic Stress Disorder (PTSD)
ICR Details
2900-0659 201610-2900-003
Historical Active 201309-2900-018
VA VBA-COMP-YM
Statement in Support of Claim for Service Connection for PTSD (21-0781), Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault (21-0781a)
Extension without change of a currently approved collection   No
Regular
Approved without change 07/17/2017
Retrieve Notice of Action (NOA) 04/07/2017
  Inventory as of this Action Requested Previously Approved
07/31/2020 36 Months From Approved 08/31/2017
15,240 0 15,240
17,780 0 17,780
0 0 0
VA Forms 21-0781 and 21-0781a are used to gather information about stressful incidents in service from veterans claiming compensation for PTSD. The forms request the information that is necessary for VA to conduct meaningful research of records in order to assist claimants in obtaining credible supporting evidence supporting evidence that the incidents occurred. Without this collection of information, VA would not fulfill its statutory duty to assist claimants and would be unable to properly authorize benefits.
US Code: 38 USC 5101 Name of Law: Claims and Forms
   US Code: 38 USC 5103a Name of Law: Duty to assist claimants
   US Code: 38 USC 5107a Name of Law: Claimant responsibility; benefit of the doubt
  
None
Not associated with rulemaking
  81 FR 90922 12/15/2016
82 FR 12912 03/07/2017
Yes
  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 15,240 15,240 0 0 0 0
Annual Time Burden (Hours) 17,780 17,780 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$920,450
No
No
No
No
No
Uncollected
Cynthia Harvey - Pryor 202 461-5870 [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.
04/07/2017