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Agency Information Collection (Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident): Activity Under OMB Review

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Information about this document as published in the Federal Register.

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Veterans Benefits Administration, Department of Veterans Affairs.




In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-3521), this notice announces that the Veterans Benefits Administration (VBA), Department of Veterans Affairs, will submit the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden; it includes the actual data collection instrument.


Comments must be submitted on or before December 28, 2011.


Submit written comments on the collection of information through or to VA's OMB Desk Officer, OMB Human Resources and Housing Branch, New Executive Office Building, Room 10235, Washington, DC 20503 (202) 395-7316. Start Printed Page 73022Please refer to “OMB Control No. 2900-0104” in any correspondence.

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Denise McLamb, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, (202) 461-7485, FAX (202) 461-0966 or email Please refer to “OMB Control No. 2900-0104.”

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Title: Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident, VA Form 21-4176.

OMB Control Number: 2900-0104.

Type of Review: Extension of a currently approved collection.

Abstract: VA Form 21-4176 is used to support a claim for disability benefits based on an accidental injury that a veteran incurred while in the line of duty. VA will use the data collected to determine whether the injury was accidental or a result of willful misconduct by the veteran.

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published on September 21, 2011, at pages 58566-58567.

Affected Public: Individuals or households.

Estimated Annual Burden: 2,200 hours.

Estimated Average Burden per Respondent: 30 minutes.

Frequency of Response: One-time.

Estimated Number of Respondents: 4,400.

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Dated: November 22, 2011.

By direction of the Secretary.

Denise McLamb,

Program Analyst, Enterprise Records Service.

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[FR Doc. 2011-30504 Filed 11-25-11; 8:45 am]