This form contains 130 fields organized into 48 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Additional Behavioral Changes
Additional Behavioral Changes Not Listed in 10A	Text	Provide any additional behavioral changes following the in-service personal traumatic event(s) that were not already listed in item 10A.
Alternate Signer Date Signed
Alternate Signer Date Signed Month	Date	Provide the month the alternate signer signed this form. Max length: 2 characters
Alternate Signer Date Signed Day	Date	Provide the day the alternate signer signed this form. Max length: 2 characters
Alternate Signer Date Signed Year	Date	Provide the year the alternate signer signed this form. Max length: 4 characters
Behavioral Change: Alcohol or Drug Use
Increased/Decreased Use of Alcohol or Drugs	Checkbox	Check this box if you experienced an increased or decreased use of alcohol or drugs following the traumatic event.
Alcohol or Drug Use Additional Information	Text	Provide additional information about the increased or decreased use of alcohol or drugs, including approximate time the change occurred, and any supporting documentation or records.
Behavioral Change: Depression, Panic Attacks, or Anxiety
Episodes of Depression, Panic Attacks, or Anxiety	Checkbox	Check this box if you experienced episodes of depression, panic attacks, or anxiety following the in-service personal traumatic event(s).
Depression, Panic Attacks, or Anxiety Details	Text	Provide additional information regarding episodes of depression, panic attacks, or anxiety, such as approximate time changes occurred, relevant documentation, or records.
Behavioral Change: Disciplinary or Legal Difficulties
Disciplinary or Legal Difficulties	Checkbox	Check this box if the individual experienced disciplinary or legal difficulties following the traumatic event.
Disciplinary or Legal Difficulties Additional Information	Text	Provide additional information regarding disciplinary or legal difficulties, including the approximate time the change occurred, or any relevant documentation or records.
Behavioral Change: Duty Assignment Request
Request for Change in Duty Assignment	Checkbox	Check this box if you experienced a behavioral change that led to a request for a change in your occupational series or duty assignment.
Duty Assignment Request Details	Text	Provide additional information about the request for a change in occupational series or duty assignment, including approximate time change, documentation, or records.
Behavioral Change: Eating Habits
Changes in Eating Habits	Checkbox	Check this box if you experienced changes in eating habits, such as overeating or undereating, or significant changes in weight, following the traumatic event.
Eating Habits Additional Information	Text	Provide additional information about changes in eating habits, such as overeating, undereating, or significant changes in weight, including approximate time the change occurred, relevant documentation, or records.
Behavioral Change: Healthcare Visits
Increased/Decreased Visits to Healthcare Professional, Counselor, or Treatment Facility	Checkbox	Check this box if you experienced an increase or decrease in visits to a healthcare professional, counselor, or treatment facility following the traumatic event.
Healthcare Visits Additional Information	Text	Provide additional information regarding increased or decreased visits to a healthcare professional, counselor, or treatment facility, such as the approximate time the change occurred, documentation, or records.
Behavioral Change: Over-the-Counter Medication Use
Increased/Decreased Use of Over-the-Counter Medications	Checkbox	Check this box if you experienced an increased or decreased use of over-the-counter medications following the traumatic event.
Over-the-Counter Medication Use Details	Text	Provide additional information regarding the increased or decreased use of over-the-counter medications, including approximate time changes, documentation, or records.
Behavioral Change: Performance Evaluations
Changes in Performance or Performance Evaluations	Checkbox	Check this box if you experienced changes in your performance or performance evaluations following the traumatic event.
Performance Evaluations Additional Information	Text	Provide any additional information about behavioral changes related to performance evaluations, such as the approximate time the change occurred, documentation, or records.
Behavioral Change: Prescription Medication Use
Increased/Decreased Use of Prescription Medications	Checkbox	Check this box if you experienced an increased or decreased use of prescription medications following the traumatic event.
Prescription Medication Use Details	Text	Provide additional information about the behavioral change concerning increased or decreased use of prescription medications, including approximate time change occurred, documentation, or records.
Behavioral Change: Use of Leave
Increased/Decreased Use of Leave	Checkbox	Check this box if you experienced an increased or decreased use of leave following the in-service personal traumatic event(s).
Use of Leave Change Details	Text	Provide additional information about the increased or decreased use of leave, including approximate time the change occurred, any documentation, or records.
Changes in or Breakup of Significant Relationship
Changes in or Breakup of a Significant Relationship	Checkbox	Check this box if there were changes in or a breakup of a significant relationship.
Significant Relationship Changes/Breakup	Text	Provide details regarding any changes in or breakup of a significant relationship.
Consent Option for VHA Notification
I Consent to Notify VHA about Events	Checkbox	Check this box if you give your consent for the Veterans Benefits Administration (VBA) to notify the Veterans Health Administration (VHA) about upcoming events related to your claim and/or appeal.
I Do Not Consent to Notify VHA about Events	Checkbox	Check this box if you do not give your consent for the Veterans Benefits Administration (VBA) to notify the Veterans Health Administration (VHA) about upcoming events related to your claim and/or appeal.
I Revoke Prior Consent to Notify VHA about Events	Checkbox	Check this box if you wish to revoke any prior consent given for the Veterans Benefits Administration (VBA) to notify the Veterans Health Administration (VHA) about upcoming events related to your claim and/or appeal.
Not Applicable / Not Enrolled in VHA Healthcare	Checkbox	Check this box if this notification option is not applicable to you, or if you are not currently enrolled or registered in VHA healthcare.
Date of Birth
Date of Birth Month	Text	Enter the two-digit month of the veteran or service member's birth. Max length: 2 characters
Date of Birth Day	Text	Enter the two-digit day of the veteran or service member's birth. Max length: 2 characters
Date of Birth Year	Text	Enter the four-digit year of the veteran or service member's birth. Max length: 4 characters
Date Signed
Signed Date Month	Date	Provide the two-digit month for when the document was signed. Max length: 2 characters
Signed Date Day	Date	Provide the two-digit day for when the document was signed. Max length: 2 characters
Signed Date Year	Date	Provide the four-digit year for when the document was signed. Max length: 4 characters
E-mail Address
Email Address	Text	Enter your email address.
Economic or Social Behavioral Changes
Economic or Social Behavioral Changes	Checkbox	Check this box if there were economic or social behavioral changes associated with the in-service traumatic event(s).
Economic or Social Behavioral Changes	Text	Provide details regarding any economic or social behavioral changes.
Fifth Traumatic Event Information
Fifth Traumatic Event Detail 1	Text	Provide the first specific detail for the fifth traumatic event.
Fifth Traumatic Event Detail 2	Text	Provide the second specific detail for the fifth traumatic event.
Fifth Traumatic Event Detail 3	Text	Provide the third specific detail for the fifth traumatic event.
First Traumatic Event Details
First Traumatic Event Description	Text	Provide a brief summary of the nature of the first traumatic event, such as injury in warfare, physical assault, sexual harassment, or witnessing the death or injury of a person.
First Traumatic Event Location	Text	Specify the location where the first traumatic event occurred, such as unit assignment, residence, off-base, duty station, or state, if known.
First Traumatic Event Date	Text	Enter the date(s) or approximate dates when the first traumatic event occurred, including month(s) or year(s), if known.
First Treatment Information
First Treatment - Don't have date	Checkbox	Check this box if you do not have the date(s) for the first treatment.
First Treatment Year	Text	Enter the four-digit year (YYYY) when the first treatment began. Max length: 4 characters
First Treatment Month	Text	Enter the two-digit month (MM) when the first treatment began. Max length: 2 characters
First Treatment Facility Name and Location	Text	Enter the name and location of the first treatment facility.
First Witness Name and Address
First Witness Name and Address	Text	Enter the printed name and address of the first witness.
Fourth Traumatic Event Information
Fourth Traumatic Event Description	Text	Please provide a detailed description of the fourth traumatic event.
Fourth Traumatic Event Date/Time	Text	Please enter the date or time frame when the fourth traumatic event occurred.
Fourth Traumatic Event Location	Text	Please provide the location where the fourth traumatic event took place.
General
16. A. VETERAN/SERVICE MEMBER'S SIGNATURE	Signature
19. A. ALTERNATIE SIGNER SIGNATURE	Signature
20. A. POA/AUTHORIZED REPRESENTATIVE'S SIGNATURE	Signature
International Phone Number
International Phone Number	Text	Provide the international phone number, if applicable.
Official Report Filed
Official Report Filed - Yes	Radiobutton	Check this box if an official report was filed.
Official Report Filed - No	Radiobutton	Check this box if an official report was not filed, and skip to Item 12.
Other Report Type Details
Other Report Type	Radiobutton	Check this box if the report filed is an 'Other' type, such as an After Action Report (AAR), incident report, formal complaint, Judge Advocate General (JAG) report, Criminal Investigative Division (CID) report, or Naval Criminal Investigative Service (NCIS) report.
Other Report Type Details	Text	Provide specific details about the other report type selected.
POA/Authorized Representative Information
POA Signed Date Month	Text	Enter the month the Power of Attorney was signed. Max length: 2 characters
POA Signed Date Day	Text	Enter the day the Power of Attorney was signed. Max length: 2 characters
POA Signed Date Year	Number	Enter the year the Power of Attorney was signed. Max length: 4 characters
POA Last Form Submitted Month	Text	Enter the month the last VA Form 21-22 or VA Form 21-22A was submitted, if known. Max length: 2 characters
POA Last Form Submitted Day	Text	Enter the day the last VA Form 21-22 or VA Form 21-22A was submitted, if known. Max length: 2 characters
POA Last Form Submitted Year	Number	Enter the year the last VA Form 21-22 or VA Form 21-22A was submitted, if known. Max length: 4 characters
POA Accreditation Number	Text	Enter the accreditation number for the Power of Attorney or authorized representative.
Police Report Details
Police Report	Radiobutton	Check this box if an official police report was filed.
Police Report Location	Text	Provide the location where the police report was filed.
Possible Sources of Evidence
A Rape Crisis Center or Center for Domestic Abuse	Checkbox	Check this box if a rape crisis center or center for domestic abuse is a possible source of evidence following the traumatic event(s).
A Counseling Facility or Health Clinic	Checkbox	Check this box if a counseling facility or health clinic is a possible source of evidence following the traumatic event(s).
Family Members or Roommates	Checkbox	Check this box if family members or roommates are possible sources of evidence following the traumatic event(s).
A Faculty Member	Checkbox	Check this box if a faculty member is a possible source of evidence following the traumatic event(s).
Civilian Police Reports	Checkbox	Check this box if civilian police reports are possible sources of evidence following the traumatic event(s).
Medical Reports from Civilian Physicians or Caregivers	Checkbox	Check this box if medical reports from civilian physicians or caregivers who treated you immediately following the incident or sometime later are possible sources of evidence following the traumatic event(s).
A Chaplain or Clergy	Checkbox	Check this box if a chaplain or clergy is a possible source of evidence following the traumatic event(s).
Fellow Service Member(s)	Checkbox	Check this box if fellow service member(s) are possible sources of evidence following the traumatic event(s).
Personal Diaries or Journals	Checkbox	Check this box if personal diaries or journals are possible sources of evidence following the traumatic event(s).
None	Checkbox	Check this box if there are no possible sources of evidence from the provided list following the traumatic event(s).
Other (Specify below)	Checkbox	Check this box if there are other sources of evidence not listed that you wish to specify following the traumatic event(s).
Other Source of Evidence	Text	Specify any other possible sources of evidence following the traumatic event(s) not listed above.
Pregnancy Tests Around Traumatic Event
Pregnancy Tests Around Traumatic Event	Checkbox	Check this box if pregnancy tests were conducted around the time of the traumatic event(s).
Pregnancy Test Details	Text	Enter any relevant details regarding pregnancy tests around the time of the traumatic event(s).
Received Treatment for Traumatic Event
Treatment Received - Yes	Radiobutton	Check this box if you have received treatment related to the impact of the traumatic event(s) listed in Item 9A.
Treatment Received - No	Radiobutton	Check this box if you have not received treatment related to the impact of the traumatic event(s) listed in Item 9A.
Remarks
Remarks	Text	Provide any additional information that is important for us to know and may support your claim.
Second Traumatic Event Details
Second Traumatic Event Description	Text	Provide a brief summary of the nature of the second traumatic event experienced.
Second Traumatic Event Date	Date	Provide the date(s) the second traumatic event occurred.
Second Traumatic Event Location	Text	Provide the location where the second traumatic event occurred.
Second Treatment Information
13. C. NAME AND LOCATION OF THE TREATMENT FACILITY. Line 2 of 3	Text
Second Treatment Don't have date	Checkbox	Check this box if you do not have the specific date(s) of the second treatment.
13. D. DATE(S) OF TREATMENT. Enter 4 digit year	Text	Max length: 4 characters
13. D. DATE(S) OF TREATMENT. Enter 2 digit Month	Text	Max length: 2 characters
Second Witness Name and Address
Second Witness Printed Name and Address	Text	Enter the printed name and full mailing address of the second witness.
Sixth Traumatic Event Information
Sixth Traumatic Event Location	Text	Enter the location where the sixth traumatic event occurred.
Sixth Traumatic Event Date	Text	Enter the date of the sixth traumatic event.
Sixth Traumatic Event Description	Text	Provide a detailed description of the sixth traumatic event.
Social Security Number
Social Security Number (Part 2)	Text	Enter the middle two digits of the Social Security Number. Max length: 2 characters
Social Security Number (Part 1)	Text	Enter the first three digits of the Social Security Number. Max length: 3 characters
Social Security Number (Part 3)	Text	Enter the last four digits of the Social Security Number. Max length: 4 characters
Telephone Number
Telephone Number First Part	Text	Please enter the first three digits of the telephone number. Max length: 3 characters
Telephone Number Last Part	Text	Please enter the last four digits of the telephone number. Max length: 4 characters
Telephone Number Area Code	Text	Please enter the three-digit area code for the telephone number. Max length: 3 characters
Tests for Sexually Transmitted Infections
Tests for Sexually Transmitted Infections	Checkbox	Check this box if tests for sexually transmitted infections are relevant to the additional information associated with the in-service traumatic event(s).
Tests for Sexually Transmitted Infections	Text	Provide additional information regarding tests for sexually transmitted infections.
Third Traumatic Event Details
Third Traumatic Event Description	Text	Provide a brief summary of the nature of the third traumatic event experienced, including details such as injury in warfare, physical assault, sexual harassment, or witnessing the death or injury of a person.
Third Traumatic Event Dates	Text	Provide the month(s) or year(s) when the third traumatic event occurred; approximate dates are acceptable.
Third Traumatic Event Location	Text	Provide the location of the third traumatic event, such as unit assignment, residence, off-base location, duty station, or state, if known.
Third Treatment Information
Third Treatment Facility Name and Location	Text	Enter the name and location of the third treatment facility.
Third Treatment Don't Have Date	Checkbox	Check this box if you do not have the dates of treatment for the third treatment record.
Third Treatment End Date	Date	Enter the end date of the third treatment. Max length: 4 characters
Third Treatment Start Date	Date	Enter the start date of the third treatment. Max length: 2 characters
Treatment Location
Private Healthcare Provider	Checkbox	Check this box if you received treatment from a private healthcare provider, including services not associated with federal records.
VA Vet Center	Checkbox	Check this box if you received treatment at a VA Vet Center.
Community Care	Checkbox	Check this box if you received treatment through community care that was paid for by the VA.
VA Medical Center and CBOC	Checkbox	Check this box if you received treatment at a VA Medical Center (VAMC) or a Community-Based Outpatient Clinic (CBOC).
DOD Military Treatment Facility	Checkbox	Check this box if you received treatment at a Department of Defense (DOD) Military Treatment Facility (MTF).
Type of In-Service Traumatic Event(s)
Combat Traumatic Event(s)	Checkbox	Check this box if the in-service traumatic event(s) you experienced was combat-related.
Personal Traumatic Event(s) (not involving MST)	Checkbox	Check this box if the in-service traumatic event(s) you experienced was personal but did not involve military sexual trauma (MST).
Personal Traumatic Event(s) (involving MST)	Checkbox	Check this box if the in-service traumatic event(s) you experienced was personal and involved military sexual trauma (MST).
Other Traumatic Event(s)	Checkbox	Check this box if the in-service traumatic event(s) you experienced does not fall into the combat or personal traumatic event categories.
Type of Report Filed
Restricted	Radiobutton	Check this box if a Restricted report was filed.
Unrestricted	Radiobutton	Check this box if an Unrestricted report was filed.
Neither	Radiobutton	Check this box if neither a Restricted nor Unrestricted report was filed.
VA File Number
VA File Number	Text	Enter your VA File Number, if applicable. Max length: 9 characters
Veteran's Service Number
Veteran's Service Number	Text	Enter the Veteran's Service Number, if applicable. Max length: 10 characters
Veteran/Service Member's Name
Veteran/Service Member's First Name	Text	Enter the veteran or service member's first name. Max length: 12 characters
Veteran/Service Member's Last Name	Text	Enter the veteran or service member's last name. Max length: 18 characters
Veteran/Service Member's Middle Initial	Text	Enter the veteran or service member's middle initial. Max length: 1 characters

VA Form 21-0781, Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s) Instructions