Information Collection

Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)

IC 206614 under ICR 201612-2900-004 · OMB 2900-0802.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0802 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 21-0960M-1 Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12) Form
VA Form 21-0960M-1 Shoulder and Arm Conditions Disability Benefits Question VBA-21-0960M-12-ARE 3-7-2017.pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12)	Agency IC Tracking Number:	2900-NEW VBA-COMP-DB

Is this a Common Form? Yes		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 3.326 38 CFR 3.351(d) 38 CFR 3.351(e)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-0960M-12	Shoulder and Arm Conditions Disability Benefits Questionnaire	VBA-21-0960M-12-ARE 3-7-2017.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title: Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28)	FR Citation: 75 FR 29275

Number of Respondents: 50,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	25,000	25,000
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.