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Agency Information Collection (Disability Benefits Questionnaires-Group 4) 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.


Comments must be submitted on or before January 20, 2015.


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. 2900-0781” in any correspondence. During the comment period, comments may be viewed online through the FDMS.

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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. 2900-0781.”

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(a) Cranial Nerve Conditions Disability Benefits Questionnaire, VA Form 21-0960-C-3.

(b) Narcolepsy Disability Benefits Questionnaire, VA Form 21-0960-C-6.

(c) Fibromyalgia Disability Benefits Questionnaire, VA Form 21-0960-C-7.

(d) Seizure Disorders (Epilepsy) Disability Benefits Questionnaire, VA Form 21-0960-C-11.

(e) Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire, VA Form 21-0960-D-1.

(f) Endocrine Diseases (other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire, VA Form 21-0960-E-2.

(g) Thyroid & Parathyroid Conditions Disability Benefits Questionnaire, VA Form 21-0960-E-3.

(h) Hernias (Including Abdominal, Inguinal, and Femoral Hernias) Disability Benefits Questionnaire, VA Form 21-0960-H-1.

(i) HIV-Related Illnesses Disability Benefits Questionnaire, VA Form 21-0960-I-2.

(j) Infectious Diseases (other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire, VA Form 21-0960I-3.

(k) Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire, VA Form 21-0960-I-4.

(l) Nutritional Deficiencies Disability Benefits Questionnaire, VA Form 21-0960-I-5.

(m) Urinary Tract (including Bladder & Urethra) Conditions (excluding Male Reproductive System) Disability Benefits Questionnaire, VA Form 21-0960-J-4.

(n) Respiratory Conditions (other than Tuberculosis and Sleep Apnea) Start Printed Page 75619Disability Benefits Questionnaire, VA Form 21-0960-L-1.

(o) Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire, VA Form 21-0960-N-3.

(p) Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx, and Pharynx Disability Benefits Questionnaire, VA Form 21-0960-N-4.

(q) Chronic Fatigue Syndrome Disability Benefits Questionnaire, VA Form 21-0960-Q-1.

OMB Control Number: 2900-0781.

Type of Review: Revision

Abstract: Data collected on VA Form 21-0960 series will be used to obtain information from claimant's 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 August 28, 2014, at pages 51399-51400.

Affected Public: Individuals or households.

Estimated Annual Burden: 53,750 hours.

(a) VAF 21-0960-C-3—5,000

(b) VAF 21-0960-C-6—1,250

(c) VAF 21-0960-C-7—1,250

(d) VAF 21-0960-C-11—1,250

(e) VAF 21-0960-D-1—1,250

(f) VAF 21-0960-E-2—2,500

(g) VAF 21-0960-E-3—2,500

(h) VAF 21-0960-H-1—3,750

(i) VAF 21-0960-I-2—1,250

(j) VAF 21-0960-I-3—2,500

(k) VAF 21-0960-I-4—2,500

(l) VAF 21-0960-I-5—1,250

(m) VAF 21-0960-J-4—3,750

(n) VAF 21-0960-L-1—10,000

(o) VAF 21-0960-N-3—1,250

(p) VAF 21-0960-N-4—10,000

(q) VAF 21-0960-Q-1—2,500

Estimated Average Burden Per Respondent:

(a) VAF 21-0960-C-3—30 minutes

(b) VAF 21-0960-C-6—15 minutes

(c) VAF 21-0960-C-7—15 minutes

(d) VAF 21-0960-C-11—15 minutes

(e) VAF 21-0960-D-1—15 minutes

(f) VAF 21-0960-E-2—15 minutes

(g) VAF 21-0960-E-3—15 minutes

(h) VAF 21-0960-H-1—15 minutes

(i) VAF 21-0960-I-2—15 minutes

(j) VAF 21-0960-I-3—15 minutes

(k) VAF 21-0960-I-4—30 minutes

(l) VAF 21-0960-I-5—15 minutes

(m) VAF 21-0960-J-4—15 minutes

(n) VAF 21-0960-L-1—30 minutes

(o) VAF 21-0960-N-3—15 minutes

(p) VAF 21-0960-N-4—30 minutes

(q) VAF 21-0960-Q-1—15 minutes

Frequency of Response: On occasion.

Estimated Number of Respondents: TOTAL: 160,000.

(a) VAF 21-0960-C-3—10,000

(b) VAF 21-0960-C-6—5,000

(c) VAF 21-0960-C-7—5,000

(d) VAF 21-0960-C-11—5,000

(e) VAF 21-0960-D-1—5,000

(f) VAF 21-0960-E-2—10,000

(g) VAF 21-0960-E-3—10,000

(h) VAF 21-0960-H-1—15,000

(i) VAF 21-0960-I-2—5,000

(j) VAF 21-0960-I-3—10,000

(k) VAF 21-0960-I-4—5,000

(l) VAF 21-0960-I-5—5,000

(m) VAF 21-0960-J-4—15,000

(n) VAF 21-0960-L-1—20,000

(o) VAF 21-0960-N-3—5,000

(p) VAF 21-0960-N-4—20,000

(q) VAF 21-0960-Q-1—10,000

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Dated: December 15, 2014.

By direction of the Secretary.

Crystal Rennie,

VA Clearance Officer, Department of Veterans Affairs.

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[FR Doc. 2014-29630 Filed 12-17-14; 8:45 am]