Table of Contents
The VA Form 21-0781A is an essential document for veterans seeking to establish a connection between their military service and post-traumatic stress disorder (PTSD) stemming from personal assault. This form is specifically designed to gather detailed information about stressful incidents experienced during service, which may have contributed to the development of PTSD. Veterans are encouraged to provide comprehensive descriptions of these incidents, including dates, locations, and unit assignments, as this information is crucial for the Department of Veterans Affairs (VA) to thoroughly research military records and other relevant sources. The form also allows veterans to identify additional sources of information, such as fellow service members or health care providers, who can support their claims. It is important to fill out the form accurately and completely, as any missing details could hinder the processing of the claim. The VA recognizes the emotional toll that such incidents can take, and they provide resources, including the Veterans Crisis Line, for those in immediate need of support. By taking the time to complete the VA Form 21-0781A, veterans can take a significant step toward receiving the benefits and assistance they deserve.
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 |
File Specs
| Fact Name | Details |
|---|---|
| Form Purpose | This form is used to support claims for service connection for post-traumatic stress disorder (PTSD) secondary to personal assault. |
| OMB Approval | The form is approved by the Office of Management and Budget (OMB) under number 2900-0659. |
| Estimated Completion Time | Respondents are estimated to spend about 1 hour and 10 minutes completing the form. |
| Expiration Date | The current version of the form expired on July 31, 2020. |
| Veterans Crisis Line | A crisis support line is available at 1-800-273-8255, offering confidential support 24/7. |
| Information Required | Veterans must provide detailed descriptions of stressful incidents, including dates and locations, to support their claims. |
| Privacy Act Compliance | The form adheres to the Privacy Act of 1974, ensuring confidentiality of the information provided. |
| Legal Basis | The request for information is authorized under Title 38, United States Code, Section 5107(a). |
Va 21 0781A - Usage Guidelines
Completing the VA Form 21-0781A is an important step in supporting a claim for service connection for post-traumatic stress disorder (PTSD) secondary to personal assault. This form requires detailed information about stressful incidents experienced during military service. Accuracy and thoroughness are crucial, as the information provided will assist in the evaluation of the claim.
- Begin by obtaining the VA Form 21-0781A. This form can be filled out online or printed for handwritten completion.
- In Section I, enter the veteran's identification information:
- Full 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 (including area code)
- Email Address (optional)
- Proceed to Section II to describe the stressful incidents:
- Enter the date of the first incident (MM-DD-YYYY).
- Provide the dates of unit assignment (From: MM-DD-YYYY to MM-DD-YYYY).
- Specify the location of the incident (City, State, Country, etc.).
- Detail the unit assignment during the incident (e.g., Division, Wing, Battalion).
- Provide a thorough description of the incident. If more space is needed, attach a separate sheet and indicate the item number to which the answers apply.
- In Section II, continue to identify other sources of information:
- List names and addresses of individuals or organizations that may provide additional information regarding the incidents.
- If applicable, mention any treatment providers and complete VA Form 21-4142 to authorize the release of records.
- In Section II, provide any other relevant information that may assist in evaluating the claim. This could include behavioral changes or other significant events following the incidents.
- Finally, in Section III, the veteran must certify the accuracy of the information:
- Sign and date the form (MM-DD-YYYY).
After completing the form, review all entries for accuracy and completeness. Submit the form to the appropriate VA office for processing. It is advisable to keep a copy of the completed form for personal records.
Your Questions, Answered
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. Veterans use this form to describe stressful incidents that occurred during their service, which they believe contributed to their current mental health condition.
Who should fill out the VA Form 21-0781A?
This form is intended for veterans who are seeking to establish a connection between their military service and PTSD related to personal assaults. If you have experienced such incidents during your service and are struggling with PTSD, this form is a crucial step in your claims process.
What information do I need to provide on the form?
You will need to provide personal identification information, including your name, social security number, and service details. Additionally, you must describe the stressful incidents, including dates, locations, and unit assignments. Be as specific as possible, as this information helps the VA conduct thorough research on your military records.
How long does it take to complete the VA Form 21-0781A?
On average, it takes about 1 hour and 10 minutes to complete the form. This includes the time needed to gather information and carefully fill out the details required for your claim.
Can I complete the form online?
Yes, you can fill out the VA Form 21-0781A online or by hand. If you choose to complete it by hand, make sure to write neatly and legibly to avoid any processing delays.
What if I need more space to describe the incidents?
If you find that the space provided on the form is insufficient, you can attach additional sheets. Just be sure to indicate which item number your answers correspond to so that the information can be properly matched to your claim.
What should I do if I have other sources of information?
If there are other individuals or organizations that can provide information about your incidents, list them on the form. This may include military or civilian authorities, counseling centers, or even personal contacts who were aware of the incidents. Providing this information can strengthen your claim.
Is there any support available if I am in crisis?
If you or someone you know is in crisis, immediate help is available. You can call the Veterans Crisis Line at 1-800-273-8255 and press 1, chat online at https://www.veteranscrisisline.net/, or send a text message to 838255. Support is confidential and available 24/7.
What happens if I don’t provide complete information?
It’s important to provide complete and accurate information on the form. If you don’t, the VA may not be able to thoroughly research your military records or support your claim for PTSD. The information you provide is confidential, so don’t hesitate to share what’s necessary.
Common mistakes
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Incomplete Information: Many people fail to provide all the necessary details in the form. Each section requires specific information, such as dates and locations of incidents. Omitting these details can delay the processing of your claim.
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Illegible Handwriting: If filling out the form by hand, it's crucial to write neatly. Illegible handwriting can lead to misunderstandings or errors in your application, which may result in a denial of your claim.
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Not Describing the Incident Thoroughly: Simply stating that an incident occurred is not enough. Providing a detailed account of what happened, including your feelings and reactions, is essential for the VA to understand the impact on your life.
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Failing to Include Supporting Evidence: Many individuals neglect to provide additional sources of information. Including statements from witnesses or medical professionals can strengthen your claim significantly.
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Missing Signatures: It's easy to overlook signing the form. Ensure that you sign and date the document before submission. A missing signature can halt the processing of your claim.
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Ignoring the Instructions: The form comes with specific instructions for a reason. Not following these instructions can lead to mistakes that may affect the outcome of your claim. Always read the guidelines carefully before filling out the form.
Documents used along the form
The VA Form 21-0781A is essential for veterans seeking to establish a claim for service connection related to post-traumatic stress disorder (PTSD) stemming from personal assault. However, several other forms and documents often accompany this form to provide additional context and support for the claim. Below is a list of these important documents.
- VA Form 21-4142: This form is used to authorize the release of medical records and other information from healthcare providers. Veterans should complete this form for each provider they want the VA to contact for supporting evidence.
- VA Form 21-526EZ: This is the application for disability compensation and related compensation benefits. Veterans must submit this form to initiate their claim for service-connected disabilities.
- VA Form 21-0781: Similar to the 21-0781A, this form is a statement in support of a claim for PTSD but is used for claims not specifically related to personal assault. It helps outline the stressors experienced during service.
- Buddy Statements: These are written statements from fellow service members or individuals who can attest to the stressful incidents experienced by the veteran. They provide firsthand accounts that can strengthen the claim.
- Medical Records: Documentation from healthcare providers detailing the veteran's mental health treatment and diagnoses. These records can help establish a link between service incidents and current mental health conditions.
- Personal Journals or Diaries: Any personal documentation that reflects the veteran's thoughts, feelings, or experiences related to the traumatic incidents. These can offer valuable insights into the veteran's state of mind following the events.
Gathering these forms and documents can significantly enhance the chances of a successful claim. Each piece of information contributes to a clearer picture of the veteran's experience and current condition, ultimately aiding the VA in making informed decisions regarding benefits.
Similar forms
The VA Form 21-0781A is designed to support claims for service connection for post-traumatic stress disorder (PTSD) related to personal assault. A similar document is the VA Form 21-0781, which is also a statement in support of a claim for PTSD. While both forms serve to gather information about stressful incidents experienced during service, the 21-0781 is broader in scope and does not specifically focus on personal assault. Instead, it allows veterans to report any traumatic events that may have contributed to their PTSD, making it applicable to a wider range of scenarios.
Another related document is the VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs. This form is often used in conjunction with the 21-0781A to authorize the release of medical or treatment records from third parties. While the 21-0781A collects information about the incidents leading to PTSD, the 21-4142 ensures that the VA can obtain relevant documentation from healthcare providers, which may help substantiate the veteran's claim.
The VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, is another similar document. This form is used to apply for disability compensation, including PTSD claims. While the 21-0781A focuses specifically on detailing the incidents that led to PTSD, the 21-526EZ encompasses a broader range of disabilities and requires the veteran to provide general information about their service and medical history.
Additionally, the VA Form 21-0781B, Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault (Buddy Statement), is relevant. This form allows a fellow service member or other individuals to provide corroborating statements regarding the stressful incidents reported by the veteran. It serves as a means of validating the claims made in the 21-0781A, reinforcing the veteran's account through eyewitness testimony.
The VA Form 21-0958, Notice of Disagreement, also bears similarity. This form is used when a veteran disagrees with a VA decision regarding their claim, including those related to PTSD. While the 21-0781A is a means to initiate a claim, the 21-0958 is a follow-up document that allows veterans to contest unfavorable decisions, ensuring they have a channel to advocate for their rights and benefits.
The VA Form 21-4138, Statement in Support of Claim, is another document that veterans may use to provide additional information about their claims. This form is less structured than the 21-0781A and allows for a more narrative approach. Veterans can use it to elaborate on their experiences, submit new evidence, or clarify details that may assist in their claim for PTSD or other service-related conditions.
Finally, the VA Form 21-530, Application for Burial Benefits, is relevant in the context of veterans' benefits. While it does not directly relate to PTSD claims, it is a part of the broader framework of VA forms that veterans may encounter. Understanding the various forms available can help veterans navigate the claims process more effectively, ensuring they receive the benefits they are entitled to, even in cases of PTSD that may arise posthumously.
Dos and Don'ts
When filling out the VA Form 21-0781A, it is essential to approach the task with care and attention to detail. This form is crucial for supporting your claim for service connection for post-traumatic stress disorder (PTSD) due to personal assault. Below are some important dos and don'ts to consider.
- Do provide detailed descriptions of each stressful incident, including dates and locations.
- Do ensure your handwriting is clear and legible if completing the form by hand.
- Do attach additional sheets if you need more space for your answers.
- Do include any other sources of information that may support your claim, such as names and addresses of individuals who can provide statements.
- Don't leave any sections blank; if a question does not apply, indicate that clearly.
- Don't rush through the form; take your time to ensure accuracy and completeness.
- Don't submit false or misleading information; this can lead to severe penalties.
- Don't forget to sign and date the form before submission to validate your claim.
By following these guidelines, you can help ensure that your application is processed smoothly and efficiently. Remember, the more accurate and detailed your information, the better the chances of your claim being supported. Take care as you complete this important document.
Misconceptions
Understanding the VA Form 21-0781A is crucial for veterans seeking support for PTSD claims. However, several misconceptions can lead to confusion. Here are ten common misunderstandings about this form:
- It’s only for veterans with combat experience. Many believe this form is exclusively for those who have experienced combat. In reality, it is designed for any veteran who has faced personal assault or other traumatic incidents during service.
- You must have a diagnosis of PTSD to use the form. Some think a formal PTSD diagnosis is necessary before filing. However, the form is intended to gather information about stressful incidents that may contribute to PTSD, regardless of a diagnosis.
- The form must be completed perfectly. Many feel pressured to fill out the form flawlessly. While thoroughness is important, the VA understands that some details may be difficult to recall. Providing as much information as possible is sufficient.
- Only incidents reported at the time matter. Some veterans believe that only documented incidents count. However, personal accounts and testimonies can also be valuable, even if they were not reported at the time.
- You need extensive evidence to support your claim. There is a misconception that extensive documentation is required. While additional evidence can strengthen a claim, personal descriptions of incidents are often sufficient for the VA to begin processing.
- The form is only for recent incidents. Some veterans think they can only report recent events. This is not true; veterans can report incidents that occurred at any time during their service.
- Completing the form guarantees approval. Many believe that submitting the form will automatically result in a successful claim. The form is a necessary step, but approval depends on various factors, including the strength of the evidence provided.
- Confidentiality is not guaranteed. Some veterans worry that their information will not be kept private. The VA is committed to protecting personal information and follows strict privacy regulations.
- It’s too late to file a claim. Some veterans think they have missed the deadline for filing. However, there is no strict time limit for submitting claims related to PTSD, especially for incidents that may have occurred long ago.
- You can’t ask for help with the form. Many believe they must complete the form alone. In fact, veterans can seek assistance from VA representatives, support organizations, or trusted friends and family members.
By addressing these misconceptions, veterans can better navigate the process of filing their claims and receive the support they deserve.
Key takeaways
When filling out the VA Form 21-0781A, it's essential to keep a few key points in mind:
- Purpose: This form is used to support claims for service connection for PTSD due to personal assault.
- Detail Matters: Provide thorough descriptions of incidents, including dates, locations, and unit assignments.
- Use Clear Language: Write legibly and clearly, whether you fill it out online or by hand.
- Include Other Sources: Identify any additional individuals or documents that can support your claim.
- Behavioral Changes: Note any significant changes in behavior after the incidents, as they can strengthen your case.
- Privacy Considerations: Your information is confidential and protected under the Privacy Act.
- Certification: Sign and date the form to certify that the information is accurate to the best of your knowledge.
- Seek Help if Needed: If you’re in crisis, reach out to the Veterans Crisis Line for immediate support.
Completing this form accurately and thoroughly is crucial for the success of your claim. Take your time and ensure all information is correct.