Information Collection

Employment Questionnaire (VA Form 21-4140)

IC 28229 under ICR 202404-2900-003 · OMB 2900-0079.

Documents and Forms

Document Name Document Type
Form VA Form 21-4140 Employment Questionnaire (VA Form 21-4140) Form
VA Form 21-4140 Employment Questionnaire 21-4140(5-14-24).pdf www.va.gov/vaforms Form
VA Form 21-4140 Employment Questionnaire 21-4140(5-14-24).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Employment Questionnaire (VA Form 21-4140)	Agency IC Tracking Number:	2900-0079

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.343 38 CFR 4.16 38 CFR 3.362

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 21-4140	Employment Questionnaire	21-4140(5-14-24).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 Veteran Readiness and Employment Records-VA (58VA21/22/28)	FR Citation: 87 FR 8740

Number of Respondents: 3,422	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,422	462	2,960
Annual IC Time Burden (Hours)	285	38	247
Annual IC Cost Burden (Dollars)	0	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.