Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)

ICR 201612-2900-016 · OMB 2900-0065 · Historical Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 2900-0065 can be found here:

Forms and Documents

Document	Type	Status	Availability
Form VA Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits	Form	Modified	Available
2017-08932, 30-Day FRN (2900-0065).pdf	Supplementary Document	Uploaded 2017-05-17	Available
2900-0065, Supporting Statement (VAF 21-4192).docx	Supporting Statement A	Uploaded 2017-08-17	Available
60-Day FRN_2900-0065 (Published 01-19-17).pdf	Supplementary Document	Uploaded 2017-01-26	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
28204	Request for Employment Information in Connection with Claim for Disability Benefits	Form	Modified

ICR Details

OMB Control No: 2900-0065	ICR Reference No: 201612-2900-016
Status: Historical Active	Previous ICR Reference No: 201405-2900-008
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-YA
Title: Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/14/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/08/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2020	36 Months From Approved	11/30/2017
Responses	60,000	0	60,000
Time Burden (Hours)	15,000	0	15,000
Cost Burden (Dollars)	0	0	0

Abstract: VA Form 21-4192 is used to gather necessary employment information from Veterans' employers so VA can determine eligibility to increased disability benefits based on unemployability.

Authorizing Statute(s): US Code: 38 USC 1502 Name of Law: Determinations with Respect to Disability

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 6729	01/19/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 20686	05/03/2017
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
Request for Employment Information in Connection with Claim for Disability Benefits	VA Form 21-4192	REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	60,000	60,000
Annual Time Burden (Hours)	15,000	15,000
Annual Cost Burden (Dollars)	0	0

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: $2,578,333

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

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: No