Non-Degenerative Arthritis (including inflammatory, autoimmune, crystalline and infectious arthritis) and Dysbaric Osteonecrosis Disability Benefits Questionnaire (21-0960M-3)

ICR 201612-2900-003 · OMB 2900-0801 · Historical Inactive

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 2900-0801 can be found here:

2017-09-29 - Extension without change of a currently approved collection

Forms and Documents

Document	Type	Status	Availability
Form VA Form 21-0960M-3 Non-Degenerative Arthritis (including inflammatory, autoimmune, crystalline and infections arthritis) and Dysbaric Osteonecrosis Disability Benefits Questionnaire	Form	Modified	Available
2017-05380, 30-Day FRN (2900-0801).pdf	Supplementary Document	Uploaded 2017-03-30	Available
2017-00624, 60-Day FRN (2900-0801).pdf	Supplementary Document	Uploaded 2017-02-24	Available
2900-0801, Supporting Statement (21-0960M-3).doc	Supporting Statement A	Uploaded 2017-02-24	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
206553	Non-Degenerative Arthritis (including inflammatory, autoimmune, crystalline and infections arthritis) and Dysbaric Osteonecrosis Disability Benefits Questionnaire	Form	Modified

ICR Details

OMB Control No: 2900-0801	ICR Reference No: 201612-2900-003
Status: Historical Inactive	Previous ICR Reference No: 201304-2900-009
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-DJ
Title: Non-Degenerative Arthritis (including inflammatory, autoimmune, crystalline and infectious arthritis) and Dysbaric Osteonecrosis Disability Benefits Questionnaire (21-0960M-3)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: Yes
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 09/29/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/30/2017
Terms of Clearance: VA withdraws this collection to make a technical correction to the way it was submitted.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved	12/31/2017
Responses	100,000	0	100,000
Time Burden (Hours)	25,000	0	25,000
Cost Burden (Dollars)	0	0	0

Abstract: The form will be used to gather necessary information from a claimant's treating physician regarding the results of medical examinations. VA will gather medical information related to the claimant that is necessary to adjudicate the claim for VA disability benefits.

Authorizing Statute(s): US Code: 38 USC 501(a) Name of Law: Rules and Regulations

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 4461	01/13/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 14276	03/17/2017
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Non-Degenerative Arthritis (including inflammatory, autoimmune, crystalline and infections arthritis) and Dysbaric Osteonecrosis Disability Benefits Questionnaire	VA Form 21-0960M-3	Non-Degenerative Arthritis (including inflammatory, autoimmune, crystalline and infections arthritis) and Dysbaric Osteonecrosis Disability Benefits Questionaire

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

Annual Cost to Federal Government: $8,708,700

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Cynthia Harvey - Pryor 202 461-5870 [email protected]

Common Form ICR: Yes
Description/Changes for Common Form Usage: VA Form 21-0960M-3 is being revised to include new standardization data points; to include optical character recognition boxes. This is a non-substantive change.

Approved RCFs using this ICR

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title