OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Disability Benefits Questionnaires (21-0960A-1, 21-0960B-1, 21-0960C-1)

ICR 201610-2900-005 · OMB 2900-0749 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 21-0960A-1 Disability Benefits Questionnaires Form Modified Available
2017-01744, 30-Day FRN (2900-0749).pdf Supplementary Document Uploaded 2017-02-10 Available
2016-27489 (60-Day FRN, 2900-0749).pdf Supplementary Document Uploaded 2016-12-02 Available
2900-0749 (A-1, B-1, C-1), (2-10-17).doc Supporting Statement A Uploaded 2017-02-10 Available
IC Document Collections
IC IDCollectionTypeStatusForm
193056 Disability Benefits Questionnaires Form Modified
ICR Details
2900-0749 201610-2900-005
Historical Active 201305-2900-001
VA VBA-COMP-DJ
Disability Benefits Questionnaires (21-0960A-1, 21-0960B-1, 21-0960C-1)
Extension without change of a currently approved collection   No
Regular
Approved without change 06/13/2017
Retrieve Notice of Action (NOA) 02/16/2017
  Inventory as of this Action Requested Previously Approved
06/30/2020 36 Months From Approved 06/30/2017
62,000 0 62,000
15,500 0 15,500
0 0 0
VA Form 21-0960 series is used to gather necessary information from a claimant’s treating physician regarding the results of medical examinations.
US Code: 38 USC 501a Name of Law: Veterans Benefits
  
None
Not associated with rulemaking
  81 FR 80720 11/16/2016
82 FR 8563 01/26/2017
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 62,000 62,000 0 0 0 0
Annual Time Burden (Hours) 15,500 15,500 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$5,399,394
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.
02/16/2017