Va Form 21 0781 PDF Details

For veterans looking to establish a connection between their service and current diagnoses of Post-Traumatic Stress Disorder (PTSD), the VA 21-0781 form serves as a crucial document. This form, titled "Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder," is designed to meticulously collect information about stressful incidents experienced during military service that the veteran believes contributed to their PTSD. It requires detailed descriptions of the incidents, including dates, locations, units involved, and specifics about individuals who were killed or injured. These details are essential for the Department of Veterans Affairs to conduct an in-depth review of military records in support of the claim. Veterans are urged to provide as much accurate and detailed information as possible, as this can significantly impact the outcome of the claim processing. Additionally, the form includes a privacy notice, underscoring the confidentiality with which this sensitive information is handled, as well as details about the respondent's burden, emphasizing the importance of the information's accuracy not only for the sake of validity but also because submitting false information carries severe penalties. The VA 21-0781 form stands as a testament to the commitment to acknowledging and addressing the lasting impacts of service-related stressors on veterans' lives.

QuestionAnswer
Form NameVa Form 21 0781
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesptsd form dbq form, statement ptsd, va support service connection, va claims ptsd

Form Preview Example

OMB Approved No. 2900-0659 Respondent Burden: 1 hour 10 minutes Expiration Date: 07/31/2020

STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION

FOR POST-TRAUMATIC STRESS DISORDER (PTSD)

IMPORTANT: If you or someone you know is in crisis, call the Veterans Crisis Line at 1-800-273-8255 and 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, and the full names and unit assignments of you know of who were killed or injured during the incident. Please provide dates within at least a 60-day range and do not use nicknames. It is important that you complete the form in detail and be as specific as possible so that research of military records can be thoroughly conducted. If more space is needed, attach a separate sheet, indicating the item number to which the answers apply.

VA DATE STAMP

DO NOT WRITE IN THIS SPACE

SECTION I: VETERAN'S IDENTIFICATION INFORMATION

NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.

1.VETERAN NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3.VA FILE NUMBER (If applicable)

4.DATE OF BIRTH (MM/DD/YYYY)

Month

 

 

Day

 

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. VETERAN'S SERVICE NUMBER (If applicable)

6.TELEPHONE NUMBER (Include Area Code)

7. E-MAIL ADDRESS (Optional)

SECTION II: STRESSFUL INCIDENTS

8A. DATE FIRST INCIDENT OCCURRED (MM/DD/YYYY)

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)

FROM:

Month

Day

Year

TO: Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

8F. MEDALS OR CITATIONS YOU RECEIVED BECAUSE OF THE INCIDENT

VA FORM

21-0781

SUPERSEDES VA FORM 21-0781, AUG 2014,

PAGE 1

JUL 2017

WHICH WILL NOT BE USED.

VETERAN'S SOCIAL SECURITY NO.

SECTION II: STRESSFUL INCIDENTS (CONTINUED)

NOTE: Information about persons who were killed or injured during the first incident (attach a separate sheet if more space is needed.)

9A. NAME OF PERSON (First, Middle Initial, Last)

9B. RANK (If applicable)

9C. DATE OF INJURY/DEATH (MM/DD/YYYY)

Month

 

 

 

Day

 

 

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9D. PLEASE CHECK ONE

KILLED IN ACTION WOUNDED IN ACTION OTHER

KILLED NON-BATTLE INJURED NON-BATTLE

9E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)

10A. NAME OF PERSON (First, Middle Initial, Last)

10B. RANK (If applicable)

10C. DATE OF INJURY/DEATH (MM/DD/YYYY)

Month

 

 

 

Day

 

 

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10D. PLEASE CHECK ONE

KILLED IN ACTION

WOUNDED IN ACTION

OTHER

 

 

 

KILLED NON-BATTLE

INJURED NON-BATTLE

 

 

 

 

 

 

10E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)

11A. DATE SECOND INCIDENT OCCURRED (MM,DD,YYYY)

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)

FROM: Month

Day

Year

TO:

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11C. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)

11D. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)

11E. DESCRIPTION OF THE INCIDENT

11F. MEDALS OR CITATIONS YOU RECEIVED BECAUSE OF THE INCIDENT

VA FORM 21-0781, JUL 2017

PAGE 2

VETERAN'S SOCIAL SECURITY NO.

SECTION II: STRESSFUL INCIDENTS (CONTINUED)

NOTE: Information about persons who were killed or injured during the second incident (attach a separate sheet if more space is needed.)

12A. NAME OF PERSON (First, Middle Initial, Last)

12B. RANK (If applicable) 12C. DATE OF INJURY/DEATH (MM/DD/YYYY)

Month

Day

Year

12D. PLEASE CHECK ONE

KILLED IN ACTION

WOUNDED IN ACTION

OTHER

KILLED NON-BATTLE

INJURED NON-BATTLE

 

 

 

 

 

 

12E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)

13A. NAME OF PERSON (First, Middle Initial, Last)

13B. RANK (If applicable)

13C. DATE OF INJURY/DEATH (MM/DD/YYYY)

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13D. PLEASE CHECK ONE

KILLED IN ACTION

WOUNDED IN ACTION

OTHER

KILLED NON-BATTLE

INJURED NON-BATTLE

 

 

 

 

 

 

13E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)

14. REMARKS

SECTION III: VETERAN SIGNATURE

I HEREBY CERTIFY THAT the information I have given on this form is true and correct to the best of my knowledge and belief.

15. SIGNATURE

16.DATE SIGNED (MM/DD/YYYY)

PRIVACY ACT NOTICE: 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 Vocational Rehabilitation 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 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 post-traumatic stress disorder (38 U.S.C. 5107 (a)). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 1 hour 10 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

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.

VA FORM 21-0781, JUL 2017

PAGE 3

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