Va Form 28 8861 – Fill Out and Use This PDF

Enter the First, Middle and Last Name of the Veteran in box 1.

Enter the Telephone Number, including the area code, in box 2.

Enter the Social Security Number in box 3.

Enter the Address of the Veteran in box 2.

Enter the Service Dates FROM and TO in box 5 (Mo., day, yr.).

Enter the VA File Number in box 6.

Enter the DOB in box 7 (Mo., day, yr.).

Enter the Rehabilitation Objective of the Veteran in box 8.

Enter the Anticipated Date of Rehabilitation in box 9.

Enter the Service-Connected Disabilities under 10A.

Enter the Combined Service-Connected Disability Rating under 10B.

Enter the Nonservice-Connected Disabilities under 10C.

Describe the Reasons for Referral in box 11.

Enter the Preferred Day and Time for Appointment in box 12, then sign in box 13, the Signature of Vocational Rehabilitation Specialist or Counseling Psychologist.

Enter the Telephone in box 14.

Enter the Date in box 15.

Part II is to be completed by medical personnel.

The veteran named is a participant under Chapter 31, Title 38, U.S.C. Determine whether he or she needs medical or dental treatment and, if needed, provide under appropriate VA Regulations.

If the veteran's medical condition either requires a leave of absence or makes training or employment questionable, include this information in item 16.

Enter the Report of Services Provided and Disposition of Case in 16A.

Check the box under 16B if applicable: Separate Medical Report Will Follow.

Sign in box 17, the Signature of Examining Physician, and enter the Date in box 18.

After Part II, return the form to the Vocational Rehabilitation and Counseling Division.