82 FR 19311 - Agency Information Collection Activity: Artery and Vein Conditions (Vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire, Hypertension Disability Benefits Questionnaire, Non-Ischemic Heart Disease (Including Arrhythmias and Surgery) Disability Benefits Questionnaire, Diabetic Peripheral Neuropathy (Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire, Diabetes Mellitus Disability Benefits Questionnaire, Scars/Disfigurement Disability Benefits Questionnaire, Skin Diseases Disability Benefits Questionnaire, Amputations Disability Benefits Questionnaire, Muscles Injuries Disability Benefits Questionnaire, Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire, Eye Conditions Disability Benefits Questionnaire
DEPARTMENT OF VETERANS AFFAIRS Federal Register Volume 82, Issue 79 (April 26, 2017)
Federal Register Volume 82, Issue 79 (April 26, 2017)
| Page Range | 19311-19312 | |
| FR Document | 2017-08440 |
[Federal Register Volume 82, Number 79 (Wednesday, April 26, 2017)] [Notices] [Pages 19311-19312] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2017-08440] ----------------------------------------------------------------------- DEPARTMENT OF VETERANS AFFAIRS [OMB Control No. 2900-0776] Agency Information Collection Activity: Artery and Vein Conditions (Vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire, Hypertension Disability Benefits Questionnaire, Non-Ischemic Heart Disease (Including Arrhythmias and Surgery) Disability Benefits Questionnaire, Diabetic Peripheral Neuropathy (Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire, Diabetes Mellitus Disability Benefits Questionnaire, Scars/Disfigurement Disability Benefits Questionnaire, Skin Diseases Disability Benefits Questionnaire, Amputations Disability Benefits Questionnaire, Muscles Injuries Disability Benefits Questionnaire, Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire, Eye Conditions Disability Benefits Questionnaire AGENCY: Veterans Benefits Administration, Department of Veterans Affairs. ACTION: Notice. ----------------------------------------------------------------------- SUMMARY: The Veterans Benefits Administration (VBA), Department of Veterans Affairs (VA), is announcing an opportunity for public comment on the proposed collection of certain information by the agency. Under the Paperwork Reduction Act (PRA) of 1995, Federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information, including each proposed revision of a currently approved collection, and allow 60 days for public comment in response to the notice. VA Form 21-0960 series is used to gather necessary information from a claimant's treating physician regarding the results of medical examinations. VA gathers medical information related to the claimant that is necessary to adjudicate the claim for VA disability benefits. The Disability Benefit Questionnaire title will include the name of the specific disability for which it will gather information. VAF 21-0960A- 2, Artery and Vein Conditions vascular diseases including varicose veins) Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of arteries, veins, and/or peripheral vascular disease; VAF 21-0960A-3, Hypertension, Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of hypertension; VAF 21-0960A-4, Non-ischemic Heart Disease (including Arrhythmias and Surgery) Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of any non-ischemic heart disease; VAF 21-0960C-4, Diabetic Peripheral Neuropathy (diabetic sensory-motor peripheral neuropathy) Disability Benefits Questionnaire will gather information related to the claimant's diagnosis of a diabetic sensory-motor peripheral neuropathy condition; VAF 21-0960E-1, Diabetes Mellitus Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of diabetes mellitus; VAF 21-0960F-1, Scars/ Disfigurement Disability Benefits Questionnaire will gather information related to the claimant's diagnosis of any scars or disfigurement; VAF 21-0960F-2, Skin Diseases Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of any skin disease. VAF 21-0960M-1 Amputations Disability Benefits Questionnaire, will gather information related to the claimant's amputations; VAF 21- 0960M-10 Muscle Injuries Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of a muscle injury disability. VAF 21-0960M-15 Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of temporomandibular joint dysfunction or TMJ. VAF 21-0960N-2 Eye Conditions Disability Benefits Questionnaire will gather information related to the claimant's diagnosis of an eye condition. DATES: Written comments and recommendations on the proposed collection of information should be received on or before June 26, 2017. ADDRESSES: Submit written comments on the collection of information through Federal Docket Management System (FDMS) at www.Regulations.gov or to Nancy J. Kessinger, Veterans Benefits Administration (20M33), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420 or email to [email protected]. Please refer to ``OMB Control No. 2900-0776'' in any correspondence. During the comment [[Page 19312]] period, comments may be viewed online through the FDMS. FOR FURTHER INFORMATION CONTACT: Nancy J. Kessinger at (202) 632-8924 or FAX (202) 632-8925. SUPPLEMENTARY INFORMATION: Under the PRA of 1995, Federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. This request for comment is being made pursuant to Section 3506(c)(2)(A) of the PRA. With respect to the following collection of information, VBA invites comments on: (1) Whether the proposed collection of information is necessary for the proper performance of VBA's functions, including whether the information will have practical utility; (2) the accuracy of VBA's estimate of the burden of the proposed collection of information; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) ways to minimize the burden of the collection of information on respondents, including through the use of automated collection techniques or the use of other forms of information technology. Authority: Public Law 104-13; 44 U.S.C. 3501-21. Title: (Artery and Vein Conditions (Vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire (VA Form 21-0960A-2), Hypertension Disability Benefits Questionnaire (VA Form 21-0960A-3), Non-Ischemic Heart Disease (Including Arrhythmias and Surgery) Disability Benefits Questionnaire (VA Form 21-0960A-4), Diabetic Peripheral Neuropathy (Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire (VA Form 21-0960C-4), Diabetes Mellitus Disability Benefits Questionnaire (VA Form 21-0960E-1), Scars/ Disfigurement Disability Benefits Questionnaire (VA Form 21-0960F-1), Skin Diseases Disability Benefits Questionnaire (VA Form 21-0960F-2), Amputations Disability Benefits Questionnaire (VA Form 21-0960M-1), Muscles Injuries Disability Benefits Questionnaire (VA Form 21-0960M- 10), Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire (VA Form 21-0960M-15), Eye Conditions Disability Benefits Questionnaire (VA Form 21-0960N-2)). OMB Control Number: 2900-0776. Type of Review: Extension of an approved collection. Abstract: VA Form 21-0960 series is used to gather necessary information from a claimant's treating physician regarding the results of medical examinations. VA gathers medical information related to the claimant that is necessary to adjudicate the claim for VA disability benefits. The Disability Benefit Questionnaire title will include the name of the specific disability for which it will gather information. VAF 21-0960A-2, Artery and Vein Conditions vascular diseases including varicose veins) Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of arteries, veins, and/or peripheral vascular disease; VAF 21-0960A-3, Hypertension, Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of hypertension; VAF 21-0960A-4, Non-ischemic Heart Disease (including Arrhythmias and Surgery) Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of any non-ischemic heart disease; VAF 21-0960C-4, Diabetic Peripheral Neuropathy (diabetic sensory-motor peripheral neuropathy) Disability Benefits Questionnaire will gather information related to the claimant's diagnosis of a diabetic sensory-motor peripheral neuropathy condition; VAF 21-0960E-1, Diabetes Mellitus Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of diabetes mellitus; VAF 21-0960F-1, Scars/ Disfigurement Disability Benefits Questionnaire will gather information related to the claimant's diagnosis of any scars or disfigurement; VAF 21-0960F-2, Skin Diseases Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of any skin disease. VAF 21-0960M-1 Amputations Disability Benefits Questionnaire, will gather information related to the claimant's amputations; VAF 21- 0960M-10 Muscle Injuries Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of a muscle injury disability. VAF 21-0960M-15 Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire, will gather information related to the claimant's diagnosis of temporomandibular joint dysfunction or TMJ. VAF 21-0960N-2 Eye Conditions Disability Benefits Questionnaire will gather information related to the claimant's diagnosis of an eye condition. Affected Public: Individuals or households. Estimated Annual Burden: 162,500. Estimated Average Burden per Respondent: 25 minutes. Frequency of Response: One time. Estimated Number of Respondents: 400,000. By direction of the Secretary. Cynthia Harvey-Pryor, Department Clearance Officer, Enterprise Records Service, Office of Quality and Compliance, Department of Veterans Affairs. [FR Doc. 2017-08440 Filed 4-25-17; 8:45 am] BILLING CODE 8320-01-P
![Federal Register / Vol. 82, No. 79 / Wednesday, April 26, 2017 / Notices 19311
is to conduct a survey of Veterans to By direction of the Secretary. vascular diseases including varicose
capture novel predictors of hospital Cynthia Harvey-Pryor, veins) Disability Benefits Questionnaire,
admission and identify clusters of Department Clearance Officer, Enterprise will gather information related to the
complex patients based on survey- and Records Service, Office of Quality and claimant’s diagnosis of arteries, veins,
claims-based covariates. This study Compliance, Department of Veterans Affairs. and/or peripheral vascular disease; VAF
provides the first empirical application [FR Doc. 2017–08442 Filed 4–25–17; 8:45 am] 21–0960A–3, Hypertension, Disability
of the Cycle of Complexity conceptual BILLING CODE 8320–01–P Benefits Questionnaire, will gather
model that the study team developed information related to the claimant’s
and recently published, which diagnosis of hypertension; VAF 21–
postulates that patient complexity DEPARTMENT OF VETERANS 0960A–4, Non-ischemic Heart Disease
represents more than having multiple AFFAIRS (including Arrhythmias and Surgery)
chronic conditions. It is critical to [OMB Control No. 2900–0776] Disability Benefits Questionnaire, will
evaluate whether complexity defined on gather information related to the
the basis of survey-based and claims- Agency Information Collection claimant’s diagnosis of any non-
based covariates is more predictive than Activity: Artery and Vein Conditions ischemic heart disease; VAF 21–0960C–
diagnosis of multiple chronic conditions (Vascular Diseases Including Varicose 4, Diabetic Peripheral Neuropathy
based on claims data alone. Veins) Disability Benefits (diabetic sensory-motor peripheral
The proposed patient survey is Questionnaire, Hypertension Disability neuropathy) Disability Benefits
designed to measure a broad range of Benefits Questionnaire, Non-Ischemic Questionnaire will gather information
self-reported patient factors that Heart Disease (Including Arrhythmias related to the claimant’s diagnosis of a
increase Veterans’ risk for being and Surgery) Disability Benefits diabetic sensory-motor peripheral
admitted to hospital, including life Questionnaire, Diabetic Peripheral neuropathy condition; VAF 21–0960E–
stressors, perceived locus of control, Neuropathy (Diabetic Sensory-Motor 1, Diabetes Mellitus Disability Benefits
grit, resilience, functional status, social Peripheral Neuropathy) Disability Questionnaire, will gather information
support and loneliness, sleep problems, Benefits Questionnaire, Diabetes related to the claimant’s diagnosis of
symptoms, food insecurity, and patient Mellitus Disability Benefits diabetes mellitus; VAF 21–0960F–1,
activation. This survey will help us Questionnaire, Scars/Disfigurement Scars/Disfigurement Disability Benefits
understand, for the first time, the extent Disability Benefits Questionnaire, Skin Questionnaire will gather information
to which self-reported factors can Diseases Disability Benefits related to the claimant’s diagnosis of
markedly improve prediction of patient Questionnaire, Amputations Disability any scars or disfigurement; VAF 21–
risk for hospital admission, which may Benefits Questionnaire, Muscles 0960F–2, Skin Diseases Disability
help the PACT Demonstration Lab Injuries Disability Benefits Benefits Questionnaire, will gather
Coordinating Center Intelligence Questionnaire, Temporomandibular information related to the claimant’s
improve its risk prediction models. This Joint (TMJ) Conditions Disability diagnosis of any skin disease. VAF 21–
project may also identify patient- Benefits Questionnaire, Eye 0960M–1 Amputations Disability
reported outcomes (PROs) that can be Conditions Disability Benefits Benefits Questionnaire, will gather
effectively integrated into routine VA Questionnaire information related to the claimant’s
clinical practice, as the VA begins to amputations; VAF 21–0960M–10
AGENCY: Veterans Benefits
explore inclusion of PROs into the VA Muscle Injuries Disability Benefits
Administration, Department of Veterans
electronic health record. We are Questionnaire, will gather information
Affairs.
requesting approval to conduct this related to the claimant’s diagnosis of a
ACTION: Notice. muscle injury disability. VAF 21–
survey to a nationally representative
sample of 10,000 patients who obtain SUMMARY: The Veterans Benefits 0960M–15 Temporomandibular Joint
primary care in VA because there are no Administration (VBA), Department of (TMJ) Conditions Disability Benefits
extant VA surveys that capture the range Veterans Affairs (VA), is announcing an Questionnaire, will gather information
of patient factors that we propose to opportunity for public comment on the related to the claimant’s diagnosis of
collect, which are not available in VA proposed collection of certain temporomandibular joint dysfunction or
administrative databases. If we did not information by the agency. Under the TMJ. VAF 21–0960N–2 Eye Conditions
capture these patient factors, our risk Paperwork Reduction Act (PRA) of Disability Benefits Questionnaire will
prediction analysis might be incorrect or 1995, Federal agencies are required to gather information related to the
biased. publish notice in the Federal Register claimant’s diagnosis of an eye
An agency may not conduct or concerning each proposed collection of condition.
sponsor, and a person is not required to information, including each proposed
respond to a collection of information DATES: Written comments and
revision of a currently approved recommendations on the proposed
unless it displays a currently valid OMB collection, and allow 60 days for public
control number. The Federal Register collection of information should be
comment in response to the notice. received on or before June 26, 2017.
Notice with a 60-day comment period VA Form 21–0960 series is used to
soliciting comments on this collection gather necessary information from a ADDRESSES: Submit written comments
of information was published on claimant’s treating physician regarding on the collection of information through
Thursday, January 26, 2017, Volume 82, the results of medical examinations. VA Federal Docket Management System
No. 16, pages 8563–8564. gathers medical information related to (FDMS) at www.Regulations.gov or to
mstockstill on DSK30JT082PROD with NOTICES
Affected Public: Individuals or the claimant that is necessary to Nancy J. Kessinger, Veterans Benefits
households. adjudicate the claim for VA disability Administration (20M33), Department of
Estimated Annual Burden: 2500. benefits. The Disability Benefit Veterans Affairs, 810 Vermont Avenue
Estimated Average Burden per Questionnaire title will include the NW., Washington, DC 20420 or email to
Respondent: 30 minutes. name of the specific disability for which nancy.kessinger@va.gov. Please refer to
Frequency of Response: Annually. it will gather information. VAF 21– ‘‘OMB Control No. 2900–0776’’ in any
Estimated Annual Responses: 5,000. 0960A–2, Artery and Vein Conditions correspondence. During the comment
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![19312 Federal Register / Vol. 82, No. 79 / Wednesday, April 26, 2017 / Notices
period, comments may be viewed online examinations. VA gathers medical By direction of the Secretary.
through the FDMS. information related to the claimant that Cynthia Harvey-Pryor,
FOR FURTHER INFORMATION CONTACT: is necessary to adjudicate the claim for Department Clearance Officer, Enterprise
Nancy J. Kessinger at (202) 632–8924 or VA disability benefits. The Disability Records Service, Office of Quality and
FAX (202) 632–8925. Benefit Questionnaire title will include Compliance, Department of Veterans Affairs.
SUPPLEMENTARY INFORMATION: Under the the name of the specific disability for [FR Doc. 2017–08440 Filed 4–25–17; 8:45 am]
PRA of 1995, Federal agencies must which it will gather information. VAF BILLING CODE 8320–01–P
obtain approval from the Office of 21–0960A–2, Artery and Vein
Management and Budget (OMB) for each Conditions vascular diseases including
collection of information they conduct varicose veins) Disability Benefits DEPARTMENT OF VETERANS
or sponsor. This request for comment is Questionnaire, will gather information AFFAIRS
being made pursuant to Section related to the claimant’s diagnosis of
3506(c)(2)(A) of the PRA. arteries, veins, and/or peripheral [OMB Control No. 2900–0720]
With respect to the following vascular disease; VAF 21–0960A–3,
collection of information, VBA invites Hypertension, Disability Benefits Agency Information Collection
comments on: (1) Whether the proposed Questionnaire, will gather information Activity: Operation Enduring Freedom/
collection of information is necessary related to the claimant’s diagnosis of Operation Iraqi Freedom Seriously
for the proper performance of VBA’s hypertension; VAF 21–0960A–4, Non- Injured/Ill Service Member Veteran
functions, including whether the ischemic Heart Disease (including Worksheet
information will have practical utility; Arrhythmias and Surgery) Disability
(2) the accuracy of VBA’s estimate of the Benefits Questionnaire, will gather AGENCY: Veterans Benefits
burden of the proposed collection of information related to the claimant’s Administration, Department of Veterans
information; (3) ways to enhance the diagnosis of any non-ischemic heart Affairs.
quality, utility, and clarity of the disease; VAF 21–0960C–4, Diabetic ACTION: Notice.
information to be collected; and (4) Peripheral Neuropathy (diabetic
ways to minimize the burden of the sensory-motor peripheral neuropathy) SUMMARY: The Veterans Benefits
collection of information on Disability Benefits Questionnaire will Administration (VBA), Department of
respondents, including through the use gather information related to the Veterans Affairs (VA), is announcing an
of automated collection techniques or claimant’s diagnosis of a diabetic opportunity for public comment on the
the use of other forms of information sensory-motor peripheral neuropathy
proposed collection of certain
technology. condition; VAF 21–0960E–1, Diabetes
information by the agency. Under the
Mellitus Disability Benefits
Authority: Public Law 104–13; 44 U.S.C. Paperwork Reduction Act (PRA) of
Questionnaire, will gather information
3501–21. 1995, Federal agencies are required to
related to the claimant’s diagnosis of
Title: (Artery and Vein Conditions publish notice in the Federal Register
diabetes mellitus; VAF 21–0960F–1,
(Vascular Diseases Including Varicose concerning each proposed collection of
Scars/Disfigurement Disability Benefits
Veins) Disability Benefits Questionnaire information, including each proposed
Questionnaire will gather information
(VA Form 21–0960A–2), Hypertension revision of a currently approved
related to the claimant’s diagnosis of
Disability Benefits Questionnaire (VA collection, and allow 60 days for public
any scars or disfigurement; VAF 21–
Form 21–0960A–3), Non-Ischemic Heart 0960F–2, Skin Diseases Disability comment in response to the notice. VA
Disease (Including Arrhythmias and Benefits Questionnaire, will gather Form 21–0773 is a checklist for Veterans
Surgery) Disability Benefits information related to the claimant’s Service Representatives to verify they
Questionnaire (VA Form 21–0960A–4), diagnosis of any skin disease. VAF 21– have given information, applications,
Diabetic Peripheral Neuropathy 0960M–1 Amputations Disability and/or referral service to our Operation
(Diabetic Sensory-Motor Peripheral Benefits Questionnaire, will gather Enduring Freedom or Operation Iraqi
Neuropathy) Disability Benefits information related to the claimant’s Freedom service members who have at
Questionnaire (VA Form 21–0960C–4), amputations; VAF 21–0960M–10 least six months remaining on active
Diabetes Mellitus Disability Benefits Muscle Injuries Disability Benefits duty and who may have suffered a
Questionnaire (VA Form 21–0960E–1), Questionnaire, will gather information serious injury or illness. This form will
Scars/Disfigurement Disability Benefits related to the claimant’s diagnosis of a be maintained in the veteran’s claims
Questionnaire (VA Form 21–0960F–1), muscle injury disability. VAF 21– folder.
Skin Diseases Disability Benefits 0960M–15 Temporomandibular Joint DATES: Written comments and
Questionnaire (VA Form 21–0960F–2), (TMJ) Conditions Disability Benefits recommendations on the proposed
Amputations Disability Benefits Questionnaire, will gather information collection of information should be
Questionnaire (VA Form 21–0960M–1), related to the claimant’s diagnosis of received on or before June 26, 2017.
Muscles Injuries Disability Benefits temporomandibular joint dysfunction or
Questionnaire (VA Form 21–0960M– TMJ. VAF 21–0960N–2 Eye Conditions ADDRESSES: Submit written comments
10), Temporomandibular Joint (TMJ) Disability Benefits Questionnaire will on the collection of information through
Conditions Disability Benefits gather information related to the Federal Docket Management System
Questionnaire (VA Form 21–0960M– claimant’s diagnosis of an eye (FDMS) at www.Regulations.gov or to
15), Eye Conditions Disability Benefits condition. Nancy J. Kessinger, Veterans Benefits
Administration (20M33), Department of
mstockstill on DSK30JT082PROD with NOTICES
Questionnaire (VA Form 21–0960N–2)). Affected Public: Individuals or
OMB Control Number: 2900–0776. households. Veterans Affairs, 810 Vermont Avenue
Type of Review: Extension of an Estimated Annual Burden: 162,500. NW., Washington, DC 20420 or email to
approved collection. Estimated Average Burden per nancy.kessinger@va.gov. Please refer to
Abstract: VA Form 21–0960 series is Respondent: 25 minutes. ‘‘OMB Control No. 2900–0720 ’’ in any
used to gather necessary information Frequency of Response: One time. correspondence. During the comment
from a claimant’s treating physician Estimated Number of Respondents: period, comments may be viewed online
regarding the results of medical 400,000. through the FDMS.
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Document Created: 2017-04-26 03:15:29
Document Modified: 2017-04-26 03:15:29
| Category | Regulatory Information | |
| Collection | Federal Register | |
| sudoc Class | AE 2.7: GS 4.107: AE 2.106: | |
| Publisher | Office of the Federal Register, National Archives and Records Administration | |
| Section | Notices | |
| Action | Notice. | |
| Dates | Written comments and recommendations on the proposed collection of information should be received on or before June 26, 2017. | |
| Contact | Nancy J. Kessinger at (202) 632-8924 or FAX (202) 632-8925. | |
| FR Citation | 82 FR 19311 |
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