Skip to Content


Agency Information Collection (Disability Benefits Questionnaires-Group 3) Activity Under OMB Review

Document Details

Information about this document as published in the Federal Register.

Enhanced Content

Relevant information about this document from provides additional context. This information is not part of the official Federal Register document.

Published Document

This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format.

Start Preamble


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 15, 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. 2900-0778” in any correspondence.

Start Further Info


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. 2900-0778.”

End Further Info End Preamble Start Supplemental Information



a. Central Nervous System and Neuromusculo Diseases, Disability Benefits Questionnaire, VA Form 21-0960C-5.

b. Headaches (Including Migraine Headaches), Disability Benefits Questionnaire, VA Form 21-0960C-8.

c. Multiple Sclerosis (MS), Disability Benefits Questionnaire, VA Form 21-0960C-9.

d. Esophageal Disorders (Including GERD), Disability Benefits Questionnaire, VA Form 21-0960G-1.

e. Gallbladder and Pancreas Conditions, Disability Benefits Questionnaire, VA Form 21-0960G-2.

f. Intestinal Disorders (Other Than Surgical or Infectious) (Including Irritable Bowel Syndrome, Crohn's Start Printed Page 67546Disease, Ulcerative Colitis, and Diverticulitis) Disability Benefits Questionnaire, VA Form 21-0960G-3.

g. Intestines Surgical and/or Infectious Intestinal Disorders (Bowel Resection, Colostomy, Ileostomy, Bacterial and Parasitic Infections) Disability Benefits Questionnaire, VA Form 21-0960G-4.

h. Hepatitis, Cirrhosis and Other Liver Conditions, Disability Benefits Questionnaire, VA Form 21-0960G-5.

i. Peritoneal Adhesions Disability Benefits Questionnaire, VA Form 21-0960G-6.

j. Stomach and Duodenal Conditions (Not Including GERD or Esophageal Disorders) Disability Benefits Questionnaire, VA Form 21-0960G-7.

k. Infectious Intestinal Disorders, Including Bacterial and Parasitic Infections Disability Benefits Questionnaire, VA Form 21-0960G-8.

l. Rectum and Anus Disability Benefits Questionnaire, VA Form 21-0960H-2.

m. Breast Conditions and Disorders Disability Benefits Questionnaire, VA Form 21-0960K-1.

n. Gynecological Conditions Disability Benefits Questionnaire, VA Form 21-0960K-2.

o. Sleep Apnea Disability Benefits Questionnaire, VA Form 21-0960L-2.

p. Osteomyelitis Disability Benefits Questionnaire, VA Form 21-0960M-11.

q. Ear Conditions (Including Vestibular and Infectious) Disability Benefits Questionnaire, VA Form 21-0960N-1.

OMB Control Number: 2900-0778.

Type of Review: Revised 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 April 15, 2014, at pages 48296-48297.

Affected Public: Individuals or households.

Estimated Annual Burden:

a. VA Form 21-0960C-5—5,000.

b. VA Form 21-0960C-8—3,750.

c. VA Form 21-0960C-9—7,500.

d. VA Form 21-0960G-1—10,000.

e. VA Form 21-0960G-2—1,250.

f. VA Form 21-0960G-3—1,250.

g. VA Form 21-0960G-4—1,250.

h. VA Form 21-0960G-5—5,000.

i. VA Form 21-0960G-6—1,250.

j. VA Form 21-0960G-7—2,500.

k. VA Form 21-0960G-8—1,250.

l. VA Form 21-0960H-2—2,500.

m. VA Form 21-0960K-1—7,500.

n. VA Form 21-0960K-2—10,000.

o. VA Form 21-0960L-2—1,250.

p. VA Form 21-0960M-11—10,000.

q. VA Form 21-0960N-1—6,250.

Estimated Average Burden per Respondent:

a. VA Form 21-0960C-5—30 minutes.

b. VA Form 21-0960C-8—15 minutes.

c. VA Form 21-0960C-9—45 minutes.

d. VA Form 21-0960G-1—15 minutes.

e. VA Form 21-0960G-2—15 minutes.

f. VA Form 21-0960G-3—15 minutes.

g. VA Form 21-0960G-4—15 minutes.

h. VA Form 21-0960G-5—30 minutes.

i. VA Form 21-0960G-6—15 minutes.

j. VA Form 21-0960G-7—15 minutes.

k. VA Form 21-0960G-8—15 minutes.

l. VA Form 21-0960H-2—15 minutes.

m. VA Form 21-0960K-1—15 minutes.

n. VA Form 21-0960K-2—30 minutes.

o. VA Form 21-0960L-2—15 minutes.

p. VA Form 21-0960M-11—15 minutes.

q. VA Form 21-0960N-1—15 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents:

a. VA Form 21-0960C-5—10,000.

b. VA Form 21-0960C-8—15,000.

c. VA Form 21-0960C-9—10,000.

d. VA Form 21-0960G-1—40,000.

e. VA Form 21-0960G-2—5,000.

f. VA Form 21-0960G-3—5,000.

g. VA Form 21-0960G-4—5,000.

h. VA Form 21-0960G-5—10,000.

i. VA Form 21-0960G-6—5,000.

j. VA Form 21-0960G-7—10,000.

k. VA Form 21-0960G-8—5,000.

l. VA Form 21-0960H-2—10,000.

m. VA Form 21-0960K-1—30,000.

n. VA Form 21-0960K-2—20,000.

o. VA Form 21-0960L2—5,000.

p. VA Form 21-0960M-11—40,000.

q. VA Form 21-0960N-1—25,000.

Start Signature

Dated: November 6, 2014.

By direction of the Secretary.

Crystal Rennie,

Department, Clearance Officer, Department of Veterans Affairs .

End Signature End Supplemental Information

[FR Doc. 2014-26767 Filed 11-12-14; 8:45 am]