Notice of Disagreement (VA Form 21-0958)

Forms and Documents

Document Name	Status
Form 21-0958 Notice of Disagreement (VA Form 21-0958) Form	Modified
30-day FRN (2900-0791).pdf Supplementary Document	2018-06-29
2900-0791 Supporting Stmt (VAF 21-0958) NOD 09.21.18.docx Supporting Statement A	2018-09-21
60-Day FRN (2900-0791).pdf Supplementary Document	2018-04-20

IC Document Collections

IC ID	Document Title	Status
202598	Notice of Disagreement (VA Form 21-0958) Form	Modified

ICR Details

OMB Control No: 2900-0791	ICR Reference No: 201803-2900-001
Status: Historical Active	Previous ICR Reference No: 201504-2900-001
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-YA
Title: Notice of Disagreement (VA Form 21-0958)
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: 09/27/2018
	Date Received in OIRA: 07/27/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2021	36 Months From Approved	09/30/2018
Responses	199,800	0	144,000
Time Burden (Hours)	49,950	0	72,000
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 21-0958 is used by the claimant to indicate disagreement with a decision issued by a Regional Office (RO) in order to initiate an appeal. This form is the first step in the appeal process. Without this information, appealing a decision would not be possible. VA Form 21-0958 has been updated, to include substantive changes: • The veteran’s date of birth. • The claimants information, if other than the veteran. • The burden has been decreased from 30 to 15 minutes. VA Form 21-0958 has also been revised to include new standardization data points; to include optical character recognition boxes. This is a non-substantive change.

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Authorizing Statute(s): US Code: 38 USC 1114 Name of Law: Rates of wartime disability compensation
   US Code: 38 USC 1151(1)(E) Name of Law: Benefits for persons disabled by treatment or vocational rehabilitation
   US Code: 38 USC 1311(d) Name of Law: Dependency and indemnity compensation to a surviving spouse
   US Code: 38 USC 1521(d) and (e) Name of Law: Veterans of a period of war
   US Code: 38 USC 1541(d) and (e) Name of Law: Surviving spouses of veterans of a period of war
   US Code: 38 USC 7105(a) Name of Law: Filing notice of disagreement and appeal
  

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:
	83 FR 17223	04/18/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 30225	06/27/2018
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Notice of Disagreement (VA Form 21-0958)	21-0958	Notice of Disagreement

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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	199,800	144,000	0	55,800	0	0
Annual Time Burden (Hours)	49,950	72,000	0	-22,050	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: Due to Agency discretion, the respondent burden has been decreased in half; from 30 to 15 minutes.

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Annual Cost to Federal Government: $609,963

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

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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: 07/27/2018

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