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Agency Information Collection (Disability Benefits Questionnaires-Group 2) Activity Under OMB Review

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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.

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Comments must be submitted on or before August 7, 2014.


Submit written comments on the collection of information through, or to Office of Information and Regulatory Affairs, Office of Management and Budget, Attn: VA Desk Officer; 725 17th St. NW., Washington, DC 20503 or sent through electronic mail to Please refer to “OMB Control No. 2900-0776” in any correspondence.

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Crystal Rennie, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, (202) 632-7492 or email Please refer to “OMB Control No. 2900-0776.”


a. Arteries and Veins Conditions (Vascular Diseases including Varicose Veins) Disability Benefits Questionnaire, VA Form 21-0960A-2.

b. Hypertension Disability Benefits Questionnaire, VA Form 21-0960A-3.

c. Non-Ischemic Heart Disease (including Arrhythmias and Surgery, Disability Benefits Questionnaire, VA Form 21-0960A-4.

d. Diabetic Peripheral Neuropathy (Diabetic Sensory-Motor Peripheral Neuropathy), Disability Benefits Questionnaire, VA Form 21-0960C-4.

e. Diabetes Mellitus Disability Benefits Questionnaire, VA Form 21-0960E-1.

f. Scar/Disfigurement Disability Benefits Questionnaire, VA Form 21-0960F-1.

g. Skin Diseases Disability Benefits Questionnaire, VA Form 21-0960F-2.

h. Amputations Disability Benefits Questionnaire, VA Form 21-0960M-1.

i. Muscle Injuries Disability Benefits Questionnaire, VA Form 21-0960M-10.

j. Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire, VA Form 21-0960M-15.

k. Eye Conditions Disability Benefits Questionnaire, VA Form 21-0960N-2.

OMB Control Number: 2900-0776.

Type of Review: Revision of a Currently Approved Collection.

Abstract: Data collected on VA Form 21-0960 series will be used obtain information from claimants treating physician that is necessary to adjudicate a claim for disability benefits.

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 January 17, 2014, at pages 3275-3276.

Affected Public: Individuals or households.

Estimated Annual Burden:

a. VA Form 21-0960A-2—10,000.

b. VA Form 21-0960A-3—12,500.

c. VA Form 21-0960A-4—10,000.

d. VA Form 21-0960C-4—37,500.

e. VA Form 21-0960E-1—18,750.

f. VA Form 21-0960F-1- 6,250.

g. VA Form 21-0960F-2—6,250.

h. VA Form 21-0960M-1—12,500.

i. VA Form 21-0960M-10—15,000.

j. VA Form 21-0960M-15—3,750.

k. VA Form 21-0960N-2—30,000.

Estimated Average Burden Per Respondent:

a. VA Form 21-0960A-2—30 minutes.

b. VA Form 21-0960A-3—15 minutes.

c. VA Form 21-0960A-4—30 minutes.

d. VA Form 21-0960C-4—30 minutes.

e. VA Form 21-0960E-1—15 minutes.

f. VA Form 21-0960F-1—15 minutes.

g. VA Form 21-0960F-2—15 minutes.

h. VA Form 21-0960M-1—30 minutes.

i. VA Form 21-0960M-10—30 minutes.

j. VA Form 21-0960M-15—15 minutes.

k. VA Form 21-0960N-2—45 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents:

a. VA Form 21-0960A-2—20,000.

b. VA Form 21-0960A-3—50,000.

c. VA Form 21-0960A-4—20,000.

d. VA Form 21-0960C-4—75,000.

e. VA Form 21-0960E-1—75,000.

f. VA Form 21-0960F-1—25,000.

g. VA Form 21-0960F-2—25,000.

h. VA Form 21-0960M-1—25,000.

i. VA Form 21-0960M-10—30,000.

j. VA Form 21-0960M-15—15,000.

k. VA Form 21-0960N-2—40,000.

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Dated: July 1, 2014.

By direction of the Secretary.

Crystal Rennie,

Department Clearance Officer, Department of Veterans Affairs.

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[FR Doc. 2014-15791 Filed 7-7-14; 8:45 am]