Outline
The VA Form 21-0781A, also known as the Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault, plays a crucial role for veterans seeking assistance with their claims. This form is designed to help veterans provide detailed accounts of stressful incidents that occurred during their service, which they believe contributed to their current mental health conditions. Completing this form requires veterans to list specific incidents, including dates, locations, and unit assignments, while also offering descriptions of what transpired. It's essential for veterans to be as thorough and detailed as possible, as this information aids the Department of Veterans Affairs (VA) in conducting a comprehensive review of military records and other relevant sources. The form also encourages veterans to identify additional sources of information, such as family members or health care providers, who can support their claims. While the form is straightforward, it is vital to approach it with care, ensuring that all information is accurate and complete. This not only streamlines the claims process but also helps in securing the necessary support for those who have bravely served our country.
Sample - Va 21 0781A Form
OMB Approved No.
STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION FOR POST- TRAUMATIC STRESS DISORDER (PTSD) SECONDARY TO PERSONAL ASSAULT
IMPORTANT: If you or someone you know is in crisis, call the Veterans Crisis Line at 988 and then press 1, or visit https://www.veteranscrisisline.net/ to chat online, or send a text message to 838255 to receive confidential support 24 hours a day, 7 days a week, 365 days a year. Support for deaf and hard of hearing individuals is available.
INSTRUCTIONS: List the stressful incident or incidents that occurred in service that you feel contributed to your current condition. For each incident, provide a description of what happened, the date, the geographic location, your unit assignment and dates of assignment. Please complete the form in detail and be as specific as possible so that research of military records can be thoroughly conducted. For more information, you can contact VA online through Ask VA: https://ask.va.gov/ or call us
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly and insert one letter per box to help expedite processing of the form.
1.VETERAN'S NAME (First, Middle Initial, Last)
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2. SOCIAL SECURITY NUMBER |
3. VA FILE NUMBER (If applicable) |
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4. DATE OF BIRTH (MM/DD/YYYY) |
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5. VETERAN'S SERVICE NUMBER (If applicable) |
6. TELEPHONE NUMBER (Include Area Code) |
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Enter International Phone Number (If applicable) |
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SECTION II: STRESSFUL INCIDENT(S)
8A. DATE FIRST INCIDENT OCCURRED |
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8B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY) |
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(MM/DD/YYYY) |
FROM: |
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TO: |
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8C. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)
8D. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION, CAVALRY, SHIP)
8E. DESCRIPTION OF THE INCIDENT
VA FORM |
SUPERSEDES VA FORM |
PAGE 1 |
|
JUN 2021 |
VETERAN'S SOCIAL SECURITY NO.
SECTION II: STRESSFUL INCIDENT(S) (Continued)
8E. DESCRIPTION OF INCIDENT (Continued)
9.OTHER SOURCES OF INFORMATION: Identify any other sources (military or
9A. NAME (First, Middle Initial, Last)
9B. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
State/Province
Country
ZIP Code/Postal Code
9C. NAME (First, Middle Initial, Last)
9D. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
State/Province
Country
ZIP Code/Postal Code
9E. NAME (First, Middle Initial, Last)
9F. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
State/Province
Country
ZIP Code/Postal Code
VA FORM |
PAGE 2 |
VETERAN'S SOCIAL SECURITY NO.
SECTION II: STRESSFUL INCIDENT(S) (Continued)
10.Please provide in the space below any other information that you feel is important for us to know that may help your claim. The following are some examples of behavioral changes that you may have experienced following the incident(s):
•visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment
•sudden requests for a change in occupational series or duty assignment
•increased use of leave without an apparent reason
•changes in performance and performance evaluations
•episodes of depression, panic attacks, or anxiety without an identifiable cause
•increased or decreased use of prescription medications
•increased use of
•substance abuse such as alcohol or drugs
•increased disregard for military or civilian authority
•obsessive behavior such as overeating or under eating
•pregnancy tests around the time of the incident
•tests for HIV or sexually transmitted diseases
•unexplained economic or social behavior changes
•breakup of a primary relationship
SECTION III: CERTIFICATION AND SIGNATURE
I HEREBY CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
11. VETERAN'S SIGNATURE (REQUIRED)
12.DATE SIGNED (MM/DD/YYYY)
PENALTY: The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any statement or evidence of a material fact, knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.
PRIVACY ACT INFORMATION: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in VA system of records, 58VA21/22/28, Compensation, Pension, Education and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. However, the requested information is necessary to obtain supporting evidence of stressful incidents in service. If the information is not furnished completely or accurately, VA will not be able to thoroughly research your military records and other sources for supporting evidence. The responses you submit are considered confidential (38 U.S.C. 5701).
RESPONDENT BURDEN: We need this information in order to assist you in supporting your claim for
VA FORM |
PAGE 3 |
Form Information
| Fact Name | Details |
|---|---|
| Form Purpose | This form is used to support claims for service connection for PTSD due to personal assault. |
| OMB Approval | The form has OMB approval number 2900-0659. |
| Estimated Completion Time | It takes about 1 hour and 10 minutes to complete the form. |
| Expiration Date | The current version of the form expired on July 31, 2020. |
| Veterans Crisis Line | If in crisis, veterans can call 1-800-273-8255 for support 24/7. |
| Privacy Act Notice | The information collected is confidential under the Privacy Act of 1974. |
| Governing Law | This form is governed by Title 38, United States Code, particularly sections 5107 and 5701. |
Detailed Guide for Filling Out Va 21 0781A
After completing the VA Form 21-0781A, you will need to submit it to the Department of Veterans Affairs (VA) for review. Ensure that all sections are filled out accurately and completely to support your claim for service connection related to PTSD.
- Begin with Section I: Veteran's Identification Information. Fill in the following details:
- Veteran's Name (First, Middle Initial, Last)
- Social Security Number
- VA File Number (if applicable)
- Date of Birth (MM-DD-YYYY)
- Veteran's Service Number (if applicable)
- Telephone Number (Include Area Code)
- E-mail Address (optional)
- Move to Section II: Stressful Incident(s). Provide information for each incident:
- Date First Incident Occurred (MM-DD-YYYY)
- Dates of Unit Assignment (MM-DD-YYYY) - From: To:
- Location of Incident (City, State, Country, etc.)
- Unit Assignment During Incident (e.g., Division, Wing, Battalion)
- Description of the Incident
- If more incidents occurred, continue to provide details in the same format as above.
- Identify Other Sources of Information in Section II:
- Provide names and addresses of individuals or organizations that may have information about the incident.
- If applicable, mention any treatment providers and complete VA Form 21-4142 for record retrieval.
- In Section II, provide any additional information you feel is important for your claim.
- Complete Section III: Veteran Signature:
- Sign and date the form (MM-DD-YYYY).
Obtain Answers on Va 21 0781A
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What is the VA Form 21-0781A used for?
The VA Form 21-0781A is a statement in support of a claim for service connection for post-traumatic stress disorder (PTSD) that is secondary to personal assault. This form allows veterans to provide detailed accounts of stressful incidents that occurred during their military service, which they believe have contributed to their current mental health condition.
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How do I complete the form?
To complete the form, you should provide specific information about the stressful incidents, including the date, location, and a detailed description of what happened. It is essential to be as precise as possible to facilitate thorough research of military records. If you need more space, you can attach additional sheets of paper, clearly indicating which item number your answers correspond to.
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What information do I need to provide about the incidents?
You will need to provide several details for each incident, such as:
- The date the incident occurred
- The location of the incident (city, state, or military installation)
- Your unit assignment during the incident
- A comprehensive description of the incident itself
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What if I have other sources of information?
If there are other individuals or documents that can support your claim, such as reports to military or civilian authorities, or statements from friends or family, you should include their names and contact information on the form. This can significantly strengthen your case.
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Is there a time limit for submitting this form?
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What happens after I submit the form?
Once you submit the form, the VA will review your claim and the information provided. They may contact you for additional details or clarification. It is essential to keep your contact information up to date to ensure you receive any correspondence related to your claim.
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What should I do if I am in crisis?
If you or someone you know is experiencing a crisis, immediate help is available. You can call the Veterans Crisis Line at 1-800-273-8255 and press 1 for confidential support 24/7. Alternatively, you can visit the Veterans Crisis Line website to chat online or text 838255 for assistance.
Common mistakes
When filling out the VA Form 21-0781A, individuals often make several common mistakes that can hinder the processing of their claims for service connection for post-traumatic stress disorder (PTSD). One significant error is failing to provide detailed descriptions of the stressful incidents. The form specifically requests information about what happened, including dates, locations, and unit assignments. Without this information, the VA may struggle to locate supporting evidence in military records.
Another frequent mistake is neglecting to include all relevant incidents. Many individuals focus on only one traumatic event, but the form allows for multiple incidents to be reported. Omitting additional incidents can limit the VA's understanding of the claimant's experiences and the cumulative impact these events may have had on their mental health. It is crucial to provide a comprehensive account of all relevant experiences.
Additionally, some claimants overlook the importance of including other sources of information. The form encourages individuals to identify military or non-military sources that may provide corroborating evidence. This can include names of peers, medical providers, or even personal diaries. Failing to list these sources can result in missed opportunities to strengthen the claim.
Finally, many people do not take the time to review their completed forms for accuracy and clarity. Handwritten entries should be neat and legible, and all required fields must be filled out completely. Errors or omissions in personal identification information, such as the veteran's name or social security number, can lead to delays in processing. Taking the time to carefully complete the form can significantly improve the chances of a successful claim.
Documents used along the form
The VA Form 21-0781A is a critical document used by veterans seeking service connection for post-traumatic stress disorder (PTSD) related to personal assault. Alongside this form, several other documents may be necessary to support a claim. Each of these documents serves a specific purpose in the claims process and can provide essential information to help establish a veteran's case.
- VA Form 21-4142: This form, titled "Authorization and Consent to Release Information to the Department of Veterans Affairs," allows veterans to authorize the VA to obtain medical records or other relevant information from third-party providers. It is crucial for gathering evidence that supports the claim.
- VA Form 21-0781: Similar to the 21-0781A, this form is used to report stressors that may have contributed to PTSD. It focuses more broadly on any stressful events during military service, not limited to personal assault, making it a useful companion document.
- Buddy Statements: These are personal accounts from fellow service members or individuals who can corroborate the veteran's experiences. They can provide additional context and validation of the incidents reported in the VA Form 21-0781A.
- Medical Records: Documentation from healthcare providers regarding treatment for PTSD or related conditions is vital. These records help establish a link between the veteran's service and their current mental health status.
In summary, the claims process for PTSD can be complex, and the VA Form 21-0781A is just one part of it. Utilizing additional forms and documents, such as VA Form 21-4142, VA Form 21-0781, buddy statements, and medical records, can significantly strengthen a veteran's case. Each document contributes to a comprehensive understanding of the veteran's experiences and current condition.
Similar forms
The VA Form 21-0781A is specifically designed for veterans seeking service connection for post-traumatic stress disorder (PTSD) related to personal assault. Several other forms serve similar purposes in gathering information for claims or benefits related to military service. Below are nine documents that share similarities with the VA Form 21-0781A:
- VA Form 21-0781: This form is used for veterans to report stressors related to PTSD but does not specifically address personal assault. It requires details about the incidents experienced during service.
- VA Form 21-4142: This form allows veterans to authorize the release of medical records from healthcare providers. It is often used alongside VA Form 21-0781A to obtain treatment records that support PTSD claims.
- VA Form 21-526EZ: This is the application for disability compensation and related compensation benefits. It serves as a comprehensive claim form that may reference PTSD as a condition.
- VA Form 21-0958: This form is used to appeal a decision made by the VA regarding a claim. It can be relevant if a PTSD claim is denied, allowing veterans to provide additional information or clarification.
- VA Form 21-0770: This form is used for reporting a claim for dependent benefits. While it does not directly relate to PTSD, it may be necessary for veterans with dependents who are filing for benefits.
- VA Form 21-8940: This form is for veterans seeking a total disability rating based on individual unemployability (TDIU). It can be relevant for those whose PTSD impacts their ability to work.
- VA Form 21-2680: This form is used to assess a veteran's need for aid and attendance or housebound benefits. It may be relevant for veterans whose PTSD significantly affects daily functioning.
- VA Form 21-4138: This is a statement in support of a claim. Veterans can use it to provide additional details or personal statements that may strengthen their PTSD claim.
- VA Form 21-0782: This form is utilized to report incidents of military sexual trauma (MST). It is specifically tailored for those who have experienced MST and are seeking benefits related to PTSD.
Dos and Don'ts
When filling out the VA Form 21-0781A, it is essential to approach the process with care and attention to detail. Here are some important dos and don'ts to keep in mind:
- Do provide detailed descriptions of the incidents you are reporting.
- Do include specific dates and locations for each incident.
- Do print your information clearly, using ink if completing by hand.
- Do attach additional sheets if you need more space for your answers.
- Don't leave any sections blank; provide as much information as possible.
- Don't rush through the form; take your time to ensure accuracy.
By following these guidelines, you can help ensure that your claim is processed smoothly and effectively. Remember, the more information you provide, the better the chances of receiving the support you need.
Misconceptions
Understanding the VA Form 21-0781A can be challenging, especially with the various misconceptions that surround it. Here are ten common misunderstandings about this important form:
- It’s only for combat-related PTSD. Many believe that this form is exclusively for PTSD stemming from combat experiences. In reality, it is designed for any service-related traumatic incident, including personal assaults.
- Filling it out is optional. Some veterans think that completing this form is not mandatory. However, if you are seeking service connection for PTSD, this form is crucial for your claim.
- You need to have a formal diagnosis before filling it out. Many assume that a diagnosis of PTSD is required before submitting the form. While a diagnosis can help, you can still file a claim based on your experiences and symptoms.
- The form is too complicated to complete. Some veterans feel overwhelmed by the form's requirements. While it does ask for detailed information, taking your time and being thorough can make it manageable.
- Only incidents reported to authorities count. There’s a misconception that only documented incidents matter. In truth, personal experiences, even if not reported, can still be significant in supporting your claim.
- It doesn’t matter how long ago the incident occurred. Many believe that the timing of the incident is irrelevant. However, the VA does consider the timeline, as it can help establish a connection between the incident and current symptoms.
- You can’t provide additional information later. Some think that once the form is submitted, no further information can be added. In fact, you can provide additional evidence or statements even after submission.
- Completing the form online is the only option. While online submission is convenient, veterans can also fill out the form by hand. The key is to ensure that the information is clear and legible.
- All required information must be perfect on the first try. Many fear making mistakes. It’s important to remember that it’s okay to revise your answers or seek help to clarify any uncertainties.
- The VA will automatically investigate all claims. Some believe that once they submit the form, the VA will conduct a thorough investigation. However, it’s essential for veterans to provide as much detail as possible to assist in the claim process.
Understanding these misconceptions can empower veterans to approach the VA Form 21-0781A with confidence. Taking the time to gather accurate information and share personal experiences is key to a successful claim.
Key takeaways
When filling out and using the VA Form 21-0781A, which supports claims for service connection for PTSD due to personal assault, consider the following key takeaways:
- Purpose of the Form: This form is specifically designed to document stressful incidents that may have contributed to PTSD.
- Detail is Crucial: Provide thorough descriptions of incidents, including dates, locations, and unit assignments, to facilitate accurate research.
- Additional Space: If more space is needed, attach separate sheets and clearly indicate the corresponding item number.
- Sources of Information: List any other individuals or records that may support your claim, such as treatment providers or personal diaries.
- Signature Requirement: Ensure you sign and date the form, certifying that all information is true to the best of your knowledge.
- Privacy Notice: Understand that the information provided is confidential and will only be disclosed as authorized under the Privacy Act.
- Estimated Time: Completing the form may take approximately 1 hour and 10 minutes, so plan accordingly.