Disability Benefits Questionnaires (Group 3)

Forms and Documents

Document Name	Status
Form VA Form 21-0960G-5 Disability Benefits Questionnaires (Group 3) Form	Modified
30-Day FRN (2900-0778).pdf Supplementary Document	2014-11-13
60-Day FRN (2900-0778).pdf Supplementary Document	2014-08-20
OMB2900-0778 (Group 3) (6-11-15).docx Supporting Statement A	2015-06-18

IC Document Collections

IC ID	Document Title	Status
196002	Disability Benefits Questionnaires (Group 3) Form	Modified

ICR Details

OMB Control No: 2900-0778	ICR Reference No: 201402-2900-001
Status: Historical Active	Previous ICR Reference No: 201201-2900-007
Agency/Subagency: VA	Agency Tracking No: 2900-0778 VBA-COMP-DB
Title: Disability Benefits Questionnaires (Group 3)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/22/2015
	Date Received in OIRA: 11/18/2014
Terms of Clearance: This ICR is approved for one year. Upon the next submission of this ICR for OMB approval, VA must address all substantive and non-substantive comments that were submitted by Lockheed Martin in response to the Federal Register Notice for this ICR that was published on August 15, 2014.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved	06/30/2015
Responses	250,000	0	350,000
Time Burden (Hours)	77,500	0	102,500
Cost Burden (Dollars)	0	0	0

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Abstract: This form is used to assist veteran's who require a disability examination in support of a claim for VA benefits. The forms are used to record the findings of the examining physician.

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Authorizing Statute(s): US Code: 38 USC 501(a) Name of Law: Rules and Regulations
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 158	08/15/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 219	11/13/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Disability Benefits Questionnaires (Group 3)	VA Form 21-0960G-4, VA Form 21-0960C-5, VA Form 21-0960G-8, VA Form 21-0960H-2, VA Form 21-0960G-5, VA Form 21-0960G-7, VA Form 21-0960M-11, VA Form 21-0960K-2, VA Form 21-0960L-2, VA Form 21-0960K-1, VA Form 21-0960C-8, VA Form 21-0960G-2, VA Form 21-0960C-9, VA Form 21-0960G-1, VA Form 21-0960N-1, VA Form 21-0960G-3, VA Form 21-0960G-6	Hepatitis, Cirrhosis and other Liver Conditions Disability Benefits Questionnaire ,   Stomach and Duodenal Conditions (Not including GERD or Esophageal Disorders) Disability Benefits Questionnaire ,   Ear Conditions (Including Vestibular and Infectious Conditions) Disability Benefits Questionnaire ,   Rectum and Anus Conditions Conditions (Including Hemorrhoids) Disability Benefits Questionnaire ,   Peritoneal Adhesions Disability Benefits Questionnaire ,   Intestinal Conditions (Other than Surgical or Infectious) (Including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis, and Diverticulitis) Disability Benefits Questionnaire ,   Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire ,   Central Nervous System and Neuromuscular Diseases ,   Infectious Intestinal Disorders, Including Bacterial and Parasitic Infections Disability Benefits Questionnaire ,   Osteomyelitis Disability Benefits Questionnaire ,   Gynecological Conditions Disability Benefits Questionnaire ,   Sleep Apnea Disability Benefits Questionnaire ,   Breast Conditions and Disorders Disability Benefits Questionnaire ,   Headaches (including migraine headaches) Disability Benefits Questionnaire ,   Gallbladder and Pancreas Conditions Disability Benefits Questionnaire ,   Esophageal Conditions (including gastroesophageal reflus disease (GERD), hiatal hernia and other esophageal disorders) Disability Benefits Questionnaire ,   Multiple Sclerosis (MS) Disability Benefits Questionnaire

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ICR Summary of Burden

	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	250,000	350,000	0	-100,000	0	0
Annual Time Burden (Hours)	77,500	102,500	0	-25,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The reduction in cost to the government is due to recalculation of each IC in the series. VA Form 21-0960M-3 was also removed from this collection.

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Annual Cost to Federal Government: $8,787,710

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 11/18/2014

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