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

Forms and Documents

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

IC Document Collections

IC ID	Document Title	Status
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
	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	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	60,000	60,000	0	0	0	0
Annual Time Burden (Hours)	15,000	15,000	0	0	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: 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

---

Common Form ICR:  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:

(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: 06/08/2017

---