The VA Form 21-0781a is a pivotal document designed for veterans seeking to establish a connection between their post-traumatic stress disorder (PTSD) and a personal assault event that occurred during military service. This comprehensive form requires detailed information about the stressful incident, including descriptions, dates, and locations, to facilitate thorough research of military records and other sources. Individuals are encouraged to accurately and thoroughly complete the form to assist in the processing of their claim. To begin filling out your VA Form 21-0781a, please click the button below.
Embarking on the journey to secure support for post-traumatic stress disorder (PTSD) due to personal assault during military service necessitates navigating the complexities of the VA Form 21-0781a. This documentation is a critical piece of evidence, aiming to establish a service connection for PTSD, a challenge many veterans face upon their return to civilian life. With meticulous detail required, the form prompts veterans to recount stressful incidents that they believe contributed to their current mental health condition, encompassing everything from the specifics of the incident, such as date, location, and unit assignment, to the broader impact on their lives. Not merely a bureaucratic hurdle, this form serves as a poignant intersection between a veteran’s past experiences and their quest for acknowledgment and support from the Department of Veterans Affairs (VA). Completion of this form, while potentially retraumatizing, is a fundamental step in the process toward healing, demanding an average of 1 hour and 10 minutes of reflective engagement. Moreover, instructions underscore the importance of being as precise as possible to facilitate research into military records and to aid in corroborating the claim. The VA Form 21-0781a, laden with both practical instructions for completion and a stern reminder of the legal implications of fraudulent claims, represents a lifeline for veterans seeking to make sense of their service-related PTSD, emphasizing not just the individual’s narrative, but also the broader support network including family, friends, and medical professionals who can provide corroborative statements. It’s a testament to the intersection of legal processes and human resilience in the face of adversity.
OMB Approved No. 2900-0659 Respondent Burden: 1 hour and 10 minutes Expiration Date: 06/30/2024
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 toll-free at 800-827-1000 (TTY: 711). VA forms are available at www.va.gov/vaforms. After completing the form, mail to:
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
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)
2. SOCIAL SECURITY NUMBER
3. VA FILE NUMBER (If applicable)
4. DATE OF BIRTH (MM/DD/YYYY)
5. VETERAN'S SERVICE NUMBER (If applicable)
6. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number (If applicable)
7. E-MAIL ADDRESS (Optional)
SECTION II: STRESSFUL INCIDENT(S)
8A. DATE FIRST INCIDENT OCCURRED
8B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)
(MM/DD/YYYY)
FROM:
TO:
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, JUL 2017.
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 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 and sign VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA) and VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), and fill in 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. Use VA Form 21-10210, Lay/Witness Statement, to provide these statements to the VA. These statements will help us in deciding your claim. Other sources of information also include personal diaries or journals. VA forms are available at www.va.gov/vaforms.
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)
9E. NAME (First, Middle Initial, Last)
9F. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
VA FORM 21-0781a, JUN 2021
PAGE 2
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 over-the-counter medications
•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 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.
PAGE 3
Filling out the VA Form 21-0781a is a critical step for veterans seeking service connection for Post-Traumatic Stress Disorder (PTSD) secondary to a personal assault. It's essential to approach this task methodically, providing detailed and accurate information about the stressful incidents that contributed to the condition. Since this form serves as a tool for the Department of Veterans Affairs (VA) to assess your claim and gather necessary evidence, completeness and precision are vital. Following the specified steps ensures that your submission can be processed efficiently and without unnecessary delays.
After thoroughly completing the VA Form 21-0781a and attaching any necessary additional sheets, review all sections for accuracy and completeness. Submitting a well-documented form is crucial for the VA to process your claim efficiently. The completed form, along with any supporting documents, should be submitted to the VA for evaluation. Remember, submitting this form is just one step in the claim process. It may also be beneficial to consult with a VA representative or a veterans' service organization to ensure your claim is as robust as possible.
What is VA Form 21-0781a used for?
VA Form 21-0781a is a document used by veterans to support their claim for service connection for Post-Traumatic Stress Disorder (PTSD) that is secondary to a personal assault they experienced during their military service. This form allows veterans to provide detailed information about the stressful incidents, including descriptions, dates, and locations, to assist the Department of Veterans Affairs (VA) in researching military records and other sources for evidence supporting the claim.
How long does it take to complete VA Form 21-0781a?
It takes, on average, 1 hour and 10 minutes to review the instructions, find the necessary information, and complete VA Form 21-0781a. This estimate includes time for gathering the detailed information required for a thorough submission.
Is it mandatory to fill out VA Form 21-0781a for PTSD claims related to personal assault?
While completing and submitting VA Form 21-0781a is voluntary, it is strongly recommended for veterans seeking service connection for PTSD due to personal assault. The detailed information provided in the form is critical for the VA to thoroughly research your military records and other sources to find supporting evidence for your claim. Failure to provide complete and accurate information may result in the VA being unable to support your claim adequately.
What information is required on VA Form 21-0781a?
VA Form 21-0781a requires detailed information about the veteran, including name, Social Security Number, VA File Number (if applicable), date of birth, service numbers, and contact information. The form also requests specific details about the stressful incident(s) experienced during service, such as dates, locations, unit assignments, and a thorough description of the incident. Additionally, if available, information about other sources that may provide further evidence or insight into the incident is requested.
Can additional information be attached to VA Form 21-0781a?
Yes, if more space is needed to provide a comprehensive account of the incident(s) or if there is additional information that the veteran believes will support their claim, separate sheets can be attached to VA Form 21-0781a. Be sure to indicate clearly on these sheets the item number(s) to which the information is related.
What happens if the information provided on VA Form 21-0781a is not accurate?
Submitting inaccurate information on VA Form 21-0781a can significantly affect the outcome of your claim. The VA relies on the details provided in the form to conduct a thorough investigation of military records and other sources. Inaccurate or incomplete information may lead to the rejection of your claim or a delay in processing. Additionally, knowingly submitting false information may result in penalties, including fines or imprisonment.
Who can assist with completing VA Form 21-0781a?
Veterans may seek assistance from various sources when completing VA Form 21-0781a. This includes Veterans Service Organizations (VSOs), VA-accredited agents, or attorneys specializing in veterans' benefits. These professionals can provide guidance on how to accurately complete the form and advise on the type of information and evidence that will strengthen your claim.
Where can VA Form 21-0781a be submitted?
Once completed, VA Form 21-0781a can be submitted to the Department of Veterans Affairs. Veterans can mail the completed form to the appropriate VA claims intake center, submit it in person at a VA regional office, or electronically through the VA's eBenefits portal, depending on the available options at the time of submission.
What should be done if more information becomes available after submitting VA Form 21-0781a?
If additional information or evidence becomes available after you have submitted VA Form 21-0781a, you should submit this new information to the VA as soon as possible. This can be done by including your name, Social Security Number, and the words "New Evidence" on the documents you are providing. The new information will be added to your existing claim file for consideration.
What are the consequences of not submitting VA Form 21-0781a for a PTSD claim related to personal assault?
While not mandatory, failing to submit VA Form 21-0781a may hinder your ability to successfully establish a service connection for PTSD related to personal assault. The form is designed to collect specific information that is crucial for the VA to verify the occurrence of the stressful incident(s) and to evaluate how they have contributed to your PTSD. Without this detailed information, it may be challenging for the VA to fully assess and approve your claim.
Filling out the VA Form 21-0781a, aimed at supporting a claim for Post-Traumatic Stress Disorder (PTSD) secondary to personal assault, can be crucial for veterans seeking recognition and support for their experiences. However, it's easy to make mistakes that can hinder the process. Here’s a look at common errors and how to avoid them.
One significant mistake is not providing detailed descriptions of the stressful incident(s). The form requires a thorough account, including the date, location, and what happened during the incident. Vague or incomplete descriptions can make it difficult for the VA to understand the full impact of the experience and might slow down the claim process.
Another common error is overlooking the importance of dates for both the incident and unit assignments. Specific dates help the VA verify the claim with military records. Leaving these fields blank or entering approximate dates can lead to delays in processing the claim as the VA attempts to piece together the timeline.
Many veterans also forget to list all sources of information that could support their claim. Beyond the description of the incident itself, information from fellow service members, medical records, or counseling sessions can be invaluable. Failing to provide this information can mean missing out on crucial evidence that supports the claim.
Similarly, not fully utilizing Section II, which asks for additional information, is a missed opportunity. Veterans should include any behavioral changes, substance abuse issues, or other indirect signs of PTSD. These details can offer a fuller picture of the impact of the incident and contribute to a stronger claim.
Moreover, overlooking the need to fill out additional forms like the VA Form 21-4142 for consent to release medical records can stall the process. If treatment records are relevant to the claim, not providing permission for the VA to obtain these records can prevent them from being considered.
It’s not uncommon for individuals to submit the form with incomplete sections, especially if they find it emotionally taxing to recount the incident. However, leaving sections blank or partially filled can lead to automatic rejection or requests for additional information, delaying the process.
Failing to check for accuracy in the veteran’s identification information can also be a pitfall. Mistakes in social security numbers, service numbers, or dates of birth can lead to administrative headaches and confusion.
Not attaching additional sheets when more space is needed is a mistake too. If the space provided is insufficient for a full account of the incident(s), veterans should attach separate sheets indicating the item number to which the answers apply. Without this extra information, the VA may not have a complete understanding of the claim.
In some cases, individuals neglect the privacy act notice section which states the use of the collected information. Understanding this can reassure veterans about the confidentiality and handling of their sensitive information.
Lastly, a common error is not signing and dating the form. A signature certifies that the information provided is true and correct to the best of the individual’s knowledge. Forgetting to sign can invalidate the entire submission, requiring the veteran to start the process over again.
Addressing these common errors when completing VA Form 21-0781a can streamline the process of claiming support for PTSD, ensuring that veterans receive the recognition and assistance they deserve.
When veterans apply for disability benefits due to post-traumatic stress disorder (PTSD) secondary to personal assault, the VA Form 21-0781a plays a crucial role in documenting and establishing the connection between their service and their condition. However, to provide a comprehensive and supportive claim package, several other documents and forms are often used in conjunction with VA Form 21-0781a. These documents are vital for offering detailed evidence, corroborating incidents, and presenting a well-rounded view of the impact on the veteran's life.
In the journey to secure disability benefits, each document plays a significant role in constructively building the case for a PTSD claim secondary to personal assault. Together, they provide not only the medical and service-related evidence required but also the personal context and corroboration that bring depth and clarity to the veteran's experience. By meticulously gathering and presenting these forms and documents, veterans can enhance their ability to successfully navigate the claims process and receive the benefits that reflect the true extent of their service-connected conditions.
The VA Form 21-0781 is likened to Form 21-0781a in its fundamental purpose, which is to support claims for conditions related to service. While Form 21-0781 is specifically designed for claims related to Post-Traumatic Stress Disorder (PTSD) following combat or related hostile activities, Form 21-0781a focuses on PTSD claims arising from personal trauma or assault not necessarily related to combat. Both forms require detailed descriptions of the incidents leading to PTSD, including dates, locations, and the subsequent impact on the veteran's health and behavior, underscoring their roles in facilitating the collection of evidence for claims processing.
Similar in nature to Form 21-0781a, the VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs, functions as a release form that allows the VA to obtain necessary medical records from non-VA healthcare providers. This form plays a critical role in the gathering of supporting documentation for a variety of claims, including PTSD related to personal assault. By providing consent through Form 21-4142, veterans enable the VA to access pertinent health records that can corroborate the details and aftermath of the incidents reported on Form 21-0781a.
Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, is a comprehensive form that veterans use to initiate claims for service-connected disability benefits, including PTSD. This form and VA Form 21-0781a share a common goal of assisting veterans in establishing the necessary connection between their military service and their disabilities. However, while Form 21-0781a is narrowly focused on PTSD related to personal assault, Form 21-526EZ covers a broad range of physical and psychological conditions potentially eligible for compensation.
The VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, is used by veterans to claim benefits under the Total Disability Individual Unemployability (TDIU) standard, which can include cases of severe PTSD. Despite addressing different aspects of the veterans' benefits claims process, both Form 21-8940 and Form 21-0781a are pivotal for veterans whose PTSD symptoms, whether from personal assault or other causes, hinder their ability to secure and maintain gainful employment, highlighting the interconnectedness of VA forms in addressing the comprehensive needs of veterans.
The Standard Form 180, Request Pertaining to Military Records, while not exclusive to the VA, is instrumental in obtaining military service records necessary to substantiate claims made on Form 21-0781a. These documents can include details of unit assignments, locations, and periods of service that corroborate a veteran’s account of events leading to PTSD as a result of personal assault. The ability to furnish verifiable military records through SF-180 can significantly bolster a claim’s credibility, ensuring that the veteran's narrative is supported by official documentation.
Filling out the VA Form 21-0781a is a crucial step in claiming service connection for Post-Traumatic Stress Disorder (PTSD) related to personal assault during service. Here are some essential dos and don'ts that can guide you through the process efficiently.
Do:
Don't:
Many veterans and their families have misconceptions about the VA Form 21-0781a, which is used to support claims for Post-Traumatic Stress Disorder (PTSD) due to personal assault. Here are six common misunderstandings:
Understanding these points can help veterans and their families navigate the process of claiming benefits for PTSD due to personal assault with a clearer perspective.
Filling out the VA 21-0781a form is a crucial step for veterans seeking service connection for Post-Traumatic Stress Disorder (PTSD) secondary to personal assault. Here are four key takeaways to assist veterans in accurately completing the form and supporting their claim:
Properly filling out the VA 21-0781a form with detailed, accurate information and supplementing it with evidence from other sources can significantly impact the success of a PTSD claim related to personal assault. Veterans should take the time needed to ensure their submission is as thorough and detailed as possible.
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