OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202404-2900-001 · OMB 2900-0065 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) Form Modified Repair queued
30-DAY FRN 2900-0065.pdf Supplementary Document Uploaded 2024-07-08 Repair queued
2024-09378, 60-Day FRN (VAF21-4192).pdf Supplementary Document Uploaded 2024-06-27 Repair queued
2900-0065, Supporting Statement (VAF21-4192) (2).docx Supporting Statement A Uploaded 2024-07-08 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
28204 Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) Form Modified
ICR Details
2900-0065 202404-2900-001
Received in OIRA 202009-2900-010
VA VBA-COMP-KM
Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)
Revision of a currently approved collection   No
Regular 07/08/2024
  Requested Previously Approved
36 Months From Approved 07/31/2024
48,730 25,250
12,183 6,313
0 0
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. Without this information, determination of entitlement would not be possible.
US Code: 38 USC 1502 Name of Law: Determinations with Respect to Disability
  
None
Not associated with rulemaking
  89 FR 35309 05/01/2024
89 FR 56024 07/08/2024
No
  Total Request 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 48,730 25,250 0 23,480 0 0
Annual Time Burden (Hours) 12,183 6,313 0 5,870 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
The respondent burden has increased due to the estimated number of receivables averaged over the past year.
$828,417
No
    Yes
    Yes
No
No
No
No
Maribel Aponte 202 266-4688 [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.
07/08/2024