OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 201709-2900-021 · OMB 2900-0802 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 21-0960M-12 Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12) Form Modified Repair queued
2017-07865, 30-Day FRN (2900-0802).pdf Supplementary Document Uploaded 2017-09-28 Repair queued
2017-01751, 60-Day FRN (2900-0802).pdf Supplementary Document Uploaded 2017-09-28 Repair queued
2900-0802, Supporting Statement (21-0960M-12).docx Supporting Statement A Uploaded 2017-09-28 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
206614 Shoulder and Arm Conditions Disability Benefits Questionnaire (21-0960M-12) Form Modified
ICR Details
2900-0802 201709-2900-021
Historical Active 201304-2900-029
VA VBA-COMP-DJ
Shoulder and Arm Conditions Disability Benefits Questionnaire (VA Form 21-0960M-12)
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 12/13/2017
Retrieve Notice of Action (NOA) 09/29/2017
  Inventory as of this Action Requested Previously Approved
12/31/2020 36 Months From Approved
50,000 0 0
25,000 0 0
0 0 0
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. VA Form 21-0960M-12 is being revised to include new standardization data points; to include optical character recognition boxes. This is a non-substantive change.
US Code: 38 USC 501(a) Name of Law: Rules and Regulations
  
None
Not associated with rulemaking
  82 FR 8568 01/26/2017
82 FR 18537 04/19/2017
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 50,000 0 0 0 0 50,000
Annual Time Burden (Hours) 25,000 0 0 0 0 25,000
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$4,398,333
No
    Yes
    Yes
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.
09/29/2017