VA Form 21-0781a – Fill Out and Use This PDF

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

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'S NAME (First, Middle Initial, Last)

7. E-MAIL ADDRESS (Optional)

SECTION II: STRESSFUL INCIDENT(S)

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	21-0781A	SUPERSEDES VA FORM 21-0781A, AUG 2014,	PAGE 1
JUL 2017		WHICH WILL NOT BE USED.

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 non-military) that may provide information concerning the incident in Items 9A through 9F. If you reported the incident to military or civilian authorities or sought help from a rape crisis center, counseling facility, or health clinic, etc., please provide the names and addresses and we will assist you in getting the information. If the source provided treatment and you would like us to obtain the treatment records, complete VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), for each provider. If you confided in roommates, family members, chaplains, clergy, or fellow service persons, you may want to ask them for a statement concerning their knowledge of the incident. These statements will help us in deciding your claim. Other sources of information also include personal diaries or journals.

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
		Country			ZIP Code/Postal Code
State/Province

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

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 21-0781a, JUL 2017	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		• substance abuse such as alcohol or drugs
• sudden requests for a change in occupational series or duty assignment		• increased disregard for military or civilian authority
• increased use of leave without an apparent reason		• obsessive behavior such as overeating or under eating
• changes in performance and performance evaluations		• pregnancy tests around the time of the incident
• episodes of depression, panic attacks, or anxiety without an identifiable cause		• tests for HIV or sexually transmitted diseases
• increased or decreased use of prescription medications		• unexplained economic or social behavior changes
• increased use of over-the-counter medications		• breakup of a primary relationship

SECTION III: VETERAN SIGNATURE

I HEREBY CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.

11. SIGNATURE	12. 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 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 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 and 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 21-0781a, JUL 2017	PAGE 3