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The VA Form 21-0781A plays a crucial role in the claims process for veterans seeking service connection for post-traumatic stress disorder (PTSD) that stems from personal assault during their military service. This form, officially titled "Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault," is designed to gather detailed information about the stressful incidents that veterans experienced while on active duty. Completing this form requires veterans to provide specific details, including the dates, locations, and descriptions of the incidents that contributed to their current mental health conditions. Additionally, the form encourages the inclusion of any other sources of information that may help substantiate the claim, such as testimonies from fellow service members or medical professionals. The estimated time to complete the form is about 1 hour and 10 minutes, and it is essential for veterans to provide thorough and accurate information to facilitate the VA's review process. Importantly, the form also includes a reminder for those in crisis to reach out for immediate support, highlighting the VA's commitment to the well-being of veterans. As veterans navigate this process, understanding the purpose and requirements of the VA Form 21-0781A can empower them to effectively advocate for their needs and rights.
Va 21 0781A Example
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) |
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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 Breakdown
| Fact Name | Details |
|---|---|
| Form Purpose | This form is used to support claims for service connection for PTSD related to personal assault. |
| OMB Approval | The form is approved by the Office of Management and Budget under number 2900-0659. |
| Estimated Completion Time | It is estimated that completing this form will take about 1 hour and 10 minutes. |
| Expiration Date | The expiration date for this form was July 31, 2020. |
| Governing Law | This form is governed by Title 38 of the United States Code, which pertains to veterans' benefits. |
Guide to Using Va 21 0781A
Completing the VA Form 21-0781A is an important step in supporting your claim for service connection related to PTSD due to personal assault. This form requires detailed information about stressful incidents experienced during military service. It is essential to provide accurate and comprehensive details to facilitate the processing of your claim.
- Gather Necessary Information: Before starting, collect all relevant information, including your service records, dates, locations, and any other documentation related to the incidents.
- Section I - Veteran's Identification Information: Fill in your name, Social Security number, VA file number (if applicable), date of birth, service number (if applicable), telephone number, and email address (optional).
- Section II - Stressful Incident(s): Begin with the first incident:
- 8A: Enter the date the first incident occurred (MM-DD-YYYY).
- 8B: Provide the dates of your unit assignment during that time (MM-DD-YYYY).
- 8C: Indicate the location of the incident (city, state, country, etc.).
- 8D: Specify your unit assignment during the incident.
- 8E: Describe the incident in detail. Include as much information as possible.
- If there are additional incidents, repeat the steps in Section II for each one.
- Other Sources of Information: In Section II, item 9, list any other individuals or organizations that may provide information about the incidents:
- 9A: Name of the individual or organization.
- 9B: Complete mailing address.
- 9C: Repeat for additional sources (up to 3).
- Additional Information: In Section II, item 10, provide any other relevant information that may help your claim. This can include behavioral changes or any other details you feel are important.
- Section III - Veteran Signature: Finally, sign and date the form to certify that all information provided is true and correct.
Once the form is completed, review it for accuracy and clarity. Submitting a well-prepared form can significantly impact the success of your claim. Make sure to keep a copy for your records before sending it to the appropriate VA office.
Get Answers on Va 21 0781A
What is the purpose of the VA Form 21-0781A?
The VA Form 21-0781A is designed to support claims for service connection for post-traumatic stress disorder (PTSD) that is secondary to personal assault. It allows veterans to document specific stressful incidents that occurred during their service, which they believe contributed to their current mental health condition.
How should I fill out the form?
When completing the form, it is important to provide detailed information about each stressful incident. This includes the date of the incident, its location, your unit assignment, and a thorough description of what happened. If additional space is needed, you can attach a separate sheet and reference the relevant item numbers.
What information is required in Section I?
Section I requires your identification information, including your name, social security number, VA file number (if applicable), date of birth, service number (if applicable), telephone number, and optionally, your email address. This information helps the VA to accurately identify and process your claim.
What should I do if I need more space for my descriptions?
If you find that the space provided on the form is insufficient for your descriptions, you should attach additional sheets of paper. Be sure to indicate the item number to which your answers apply so that the VA can easily reference your additional information.
What types of supporting information can I provide?
In Section II, you can identify other sources of information that may assist in substantiating your claim. This may include statements from family members, roommates, or fellow service members who were aware of the incidents. You can also mention any reports made to military or civilian authorities, as well as treatment records from healthcare providers.
How does the VA protect my privacy?
The VA is committed to maintaining the confidentiality of the information you provide. Under the Privacy Act of 1974, your responses are kept confidential and will only be disclosed as authorized. It is important to note that your obligation to respond is voluntary, but providing complete and accurate information is crucial for the thorough evaluation of your claim.
What happens if I do not provide complete information?
If the information is not furnished completely or accurately, the VA may not be able to thoroughly research your military records and other sources for supporting evidence. This could potentially delay the processing of your claim or result in a denial. It is advisable to take the time necessary to ensure that all information is correct and comprehensive.
Where can I get help if I am in crisis?
If you or someone you know is in crisis, immediate support is available. You can call the Veterans Crisis Line at 1-800-273-8255 and press 1. Additionally, you can visit Veterans Crisis Line to chat online or send a text message to 838255 for confidential support, available 24/7.
Common mistakes
Filling out the VA Form 21-0781A can be a crucial step in obtaining support for PTSD claims. However, many individuals make common mistakes that can hinder their application. One significant error is not providing enough detail about the stressful incidents. The form specifically asks for descriptions of what happened, including dates and locations. Without this information, the VA may struggle to verify the incidents, leading to delays or denials.
Another frequent mistake is neglecting to include all relevant sources of information. The form encourages veterans to identify other individuals or records that can support their claims. This includes family members, fellow service members, or even personal diaries. Failing to mention these sources can weaken the claim. It’s essential to think broadly about who or what could provide evidence.
Many people also overlook the importance of legibility. Whether filling out the form online or by hand, clarity is key. Illegible handwriting can cause misunderstandings or misinterpretations of the information provided. It’s advisable to take the time to print neatly and check for any errors before submission.
Finally, some veterans forget to sign and date the form. This may seem minor, but an unsigned form can be considered incomplete. It’s a simple step that can prevent unnecessary delays in processing the claim. Always double-check that all required fields are filled out, including the signature section.
Documents used along the form
The VA Form 21-0781A is an important document for veterans seeking support for PTSD claims related to personal assault. In addition to this form, there are several other documents that can help strengthen your claim. Below is a list of commonly used forms and documents that may be beneficial when filing a claim.
- VA Form 21-4142: This form is used to authorize the release of medical records from healthcare providers. If you received treatment for PTSD or related issues, this form allows the VA to obtain those records to support your claim.
- VA Form 21-526EZ: This is the application for disability compensation and related compensation benefits. It serves as the primary form for veterans seeking benefits for service-connected conditions, including PTSD.
- Buddy Statements: These are personal accounts from fellow service members or friends who can provide insight into the incidents that contributed to your PTSD. Their statements can add credibility to your claim.
- Personal Journals or Diaries: If you kept a journal during or after your service, these entries can provide valuable context about your experiences and how they affected your mental health. They may help illustrate the impact of the incidents on your daily life.
Gathering these documents can provide a clearer picture of your situation and help the VA in processing your claim. Each piece of information adds weight to your application, so take the time to collect them carefully.
Similar forms
The VA Form 21-0781A is designed to support claims for service connection related to PTSD due to personal assault. Several other forms serve similar purposes in gathering information or supporting claims for veterans. Below is a list of documents that share similarities with the VA Form 21-0781A:
- VA Form 21-0781: This form is a general statement in support of claims for PTSD, focusing on stressful incidents but without the specific emphasis on personal assault.
- VA Form 21-4142: This authorization form allows veterans to request the release of medical records from private healthcare providers, supporting their claims by providing necessary evidence.
- VA Form 21-526EZ: This is a claim for disability compensation and related compensation benefits, which requires detailed information about the veteran's service and conditions.
- VA Form 21-0966: This form is used to initiate a claim for disability compensation and includes a section for detailing the nature of the disability and its connection to service.
- VA Form 21-0958: This is a notice of disagreement form that veterans use to appeal a decision made by the VA regarding their claims, requiring specific information about the claim in question.
- VA Form 21-686C: This form is used to report a change in dependents, which can affect a veteran's benefits and claims for compensation.
- VA Form 21-0779: This form is for veterans seeking to apply for vocational rehabilitation and employment services, requiring details about the veteran's service and current condition.
- VA Form 21-22: This is the appointment of a representative form, allowing veterans to designate someone to assist them with their claims, which can include PTSD-related claims.
- VA Form 21-4502: This form is for veterans seeking to apply for a Certificate of Eligibility for a VA home loan, which may require information about their service and disability status.
- VA Form 21-526: This is the original claim form for veterans seeking disability compensation, which requires comprehensive information about the veteran's service and disabilities.
Dos and Don'ts
When filling out the VA Form 21-0781A, it's important to follow some guidelines to ensure your submission is complete and accurate. Here’s a list of things you should and shouldn’t do:
- Do provide detailed descriptions of each stressful incident you experienced during your service.
- Do include specific dates and locations related to each incident.
- Do print your information clearly if completing the form by hand.
- Do attach additional sheets if you need more space for your answers.
- Don’t leave any sections blank; complete all required fields.
- Don’t rush through the form; take your time to ensure accuracy.
- Don’t submit the form without reviewing it for errors or omissions.
- Don’t forget to sign and date the form before submission.
Misconceptions
The VA Form 21-0781A is essential for veterans seeking to establish a service connection for post-traumatic stress disorder (PTSD) related to personal assault. However, several misconceptions surround this form. Here are four common misunderstandings:
- Misconception 1: The form is only for veterans who experienced combat-related trauma.
- Misconception 2: Completing the form is optional and not crucial for a claim.
- Misconception 3: You need to have documented evidence of the incident to fill out the form.
- Misconception 4: The form must be completed perfectly on the first attempt.
This is not true. The VA Form 21-0781A is specifically designed for veterans who have experienced personal assaults, which can occur in various contexts, not just in combat situations. Any stressful incident during service that contributed to PTSD can be reported using this form.
In reality, submitting this form is a vital step in supporting your claim for PTSD. The information provided helps the VA thoroughly investigate your military records and assess your situation. Without it, your claim may lack the necessary evidence for approval.
While having documentation can strengthen your claim, it is not a requirement to complete the form. You can describe your experiences in detail, and the VA will assist in gathering additional information from other sources if needed.
Many veterans feel pressured to submit a flawless form, but this is not necessary. It is more important to provide as much accurate information as possible. If you need more space, attaching additional sheets is acceptable. The goal is to convey your experiences clearly.
Key takeaways
Filling out the VA Form 21-0781A is an important step for veterans seeking service connection for PTSD due to personal assault. Here are some key takeaways to keep in mind:
- Understand the Purpose: This form is specifically designed to help veterans document stressful incidents that may have contributed to PTSD.
- Be Detailed: Provide thorough descriptions of each incident, including dates, locations, and unit assignments. The more specific you are, the better.
- Use Clear Handwriting: If filling out the form by hand, ensure that your writing is legible. This helps prevent processing delays.
- Include Supporting Sources: Identify any other individuals or organizations that can provide information about the incidents. This may include counselors or fellow service members.
- Attach Additional Sheets: If you need more space for your descriptions, feel free to attach extra sheets. Just indicate which item number you are addressing.
- Behavioral Changes Matter: Mention any changes in behavior following the incidents, such as increased substance use or changes in relationships. This information can be crucial.
- Privacy is Key: Remember that the information you provide is confidential and will only be used to support your claim.
- Sign and Date: Don’t forget to sign and date the form. Your signature certifies that the information is true to the best of your knowledge.
- Seek Help if Needed: If you find the process overwhelming, consider reaching out to a veterans service organization for assistance.
By keeping these takeaways in mind, you can ensure that your VA Form 21-0781A is completed accurately and effectively, helping to support your claim for PTSD.