[Federal Register Volume 76, Number 228 (Monday, November 28, 2011)]
[Notices]
[Pages 73021-73022]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-30504]


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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0104]


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.

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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 28, 2011.

ADDRESSES: Submit written comments on the collection of information 
through http://www.Regulations.gov or to VA's OMB Desk Officer, OMB 
Human Resources and Housing Branch, New Executive Office Building, Room 
10235, Washington, DC 20503 (202) 395-7316.

[[Page 73022]]

Please refer to ``OMB Control No. 2900-0104'' in any correspondence.

FOR FURTHER INFORMATION CONTACT: Denise McLamb, Enterprise Records 
Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue 
NW, Washington, DC 20420, (202) 461-7485, FAX (202) 461-0966 or email 
[email protected]. 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 21-
4176.
    OMB Control Number: 2900-0104.
    Type of Review: Extension of a currently approved collection.
    Abstract: VA Form 21-4176 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 September 21, 2011, at pages 58566-58567.
    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 22, 2011.

    By direction of the Secretary.
Denise McLamb,
Program Analyst, Enterprise Records Service.
[FR Doc. 2011-30504 Filed 11-25-11; 8:45 am]
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