Information Collection

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

IC 28204 under ICR 202009-2900-010 · OMB 2900-0065.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0065 can be found here:

Documents and Forms

Document Name Document Type
Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) Form
21-4192 Request for Employment Information in Connection with Cl VA Form 21-4192 508 Conformant (3-23-21).pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192)	Agency IC Tracking Number:	2900-0065

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 3.340 38 CFR 3.341 38 CFR 3.342

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-4192	Request for Employment Information in Connection with Claim for Disability Benefits	VA Form 21-4192 508 Conformant (3-23-21).pdf	www.va.gov/vaforms	Yes	No	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title: Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records-VA (58VA21/22/28)	FR Citation: 84 FR 4138

Number of Respondents: 25,250	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	25,250	-34,750	60,000
Annual IC Time Burden (Hours)	6,313	-8,687	15,000
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.