2014-26719. Agency Information Collection (Report of Accidental Injury in Support of Claim for Compensation or Pension/Statement of Witness to Accident): Activity Under OMB Review

AGENCY:

Veterans Benefits Administration, Department of Veterans Affairs.

ACTION:

Notice.

SUMMARY:

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.

DATES:

Comments must be submitted on or before December 12, 2014.

ADDRESSES:

Submit written comments on the collection of information through www.Regulations.gov,, 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 [e-mail]. Please refer to “OMB Control No. 2900-0104” in any correspondence.

FOR FURTHER INFORMATION CONTACT:

Crystal Rennie, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, [phone] or email [e-mail]. Please refer to “OMB Control No. 2900-0104.”

SUPPLEMENTARY INFORMATION:

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

OMB Control Number: 2900-0104.

Type of Review: Revision of a currently approved collection.

Abstract: VA Form 21P-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 August 28, 2014, at page 51398.

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.

Dated: November 6, 2014.

By direction of the Secretary.

Crystal Rennie,

Department Clearance Officer, Department of Veterans Affairs.