VA Form 21-0781a, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault Instructions

Check this box if you experienced increased or decreased visits to a healthcare professional, counselor, or treatment facility following the traumatic event(s).

Check this box if you requested a change in occupational series or duty assignment following the traumatic event(s).

Check this box if you experienced increased or decreased use of leave following the traumatic event(s).

Check this box if there were changes in your performance or performance evaluations following the traumatic event(s).

Check this box if you experienced episodes of depression, panic attacks, or anxiety following the traumatic event(s).

Check this box if you experienced increased or decreased use of prescription medications following the traumatic event(s).

Check this box if you experienced increased or decreased use of over-the-counter medications following the traumatic event(s).

Check this box if you experienced increased or decreased use of alcohol or drugs following the traumatic event(s).

Indicate if you have experienced any disciplinary or legal difficulties as a result of the traumatic event.

Indicate if you have experienced changes in eating habits, such as overeating or undereating, or significant changes in weight due to the traumatic event.

Provide additional information about any behavioral changes you have experienced, including the approximate time the change occurred and any documentation or records.

Provide additional information about any behavioral changes you have experienced, including the approximate time the change occurred and any documentation or records.

Provide additional information about any behavioral changes you have experienced, including the approximate time the change occurred and any documentation or records.

Provide additional information about any behavioral changes you have experienced, including the approximate time the change occurred and any documentation or records.

Provide additional information about any behavioral changes you have experienced, including the approximate time the change occurred and any documentation or records.

Provide additional information about any behavioral changes you experienced, including the approximate time the changes occurred and any documentation or records that support these changes.

Provide additional information about any behavioral changes you experienced, including the approximate time the changes occurred and any documentation or records that support these changes.

Provide additional information about any behavioral changes you experienced, including the approximate time the changes occurred and any documentation or records that support these changes.

Provide additional information about any behavioral changes you experienced, including the approximate time the changes occurred and any documentation or records that support these changes.

Provide additional information about any behavioral changes you experienced, including the approximate time the changes occurred and any documentation or records that support these changes.

List any additional behavioral changes you experienced following the in-service personal traumatic event(s) that were not previously listed.

Check this box if you experienced economic or social behavioral changes.

Check this box if you experienced changes in or breakup of a significant relationship.

Provide additional information about any behavioral changes you experienced, including the approximate time the change occurred and any documentation or records available.

Provide additional information about any behavioral changes you experienced, including the approximate time the change occurred and any documentation or records available.

Provide additional information about any behavioral changes you experienced, including the approximate time the change occurred and any documentation or records available.

Provide additional information about any behavioral changes you experienced, including the approximate time the change occurred and any documentation or records available.

Check this box to consent to the VBA notifying the VHA about certain upcoming events related to your claim, such as examinations or hearings. This option is available if you are filing a claim related to a personal traumatic event involving MST.

Check this box if you do not consent to have the Veterans Benefits Administration (VBA) notify the Veterans Health Administration (VHA) about certain upcoming events related to your claim and/or appeal. Note that this will prevent these events from appearing in your VHA medical record.

Check this box if you wish to revoke your prior consent for the VBA to notify the VHA about certain upcoming events related to your claim and/or appeal. This means that future notices of these events will no longer appear in your VHA medical record.

Check this box if the consent options are not applicable to you, or if you are not enrolled or registered in VHA healthcare.

Enter your full international telephone number in standard international format, beginning with a '+' followed by the country code, area code, and subscriber number (for example, +44 20 7946 0958). Complete this field only if you have an international phone number; otherwise, leave it blank.

Enter the three-digit prefix of your U.S. telephone number (the digits immediately following the area code) in the "Telephone Number (Include Area Code)" section. Use numerals only. Complete this field when providing a domestic telephone number; if providing an international telephone number, instead use the "Enter International Phone Number (If applicable)" field.

Enter the last four digits of your primary telephone number in the Telephone Number (Include Area Code) field. Provide exactly four numeric digits (no spaces, hyphens, or other characters).

Enter the three-digit area code for your telephone number in the first field of Telephone Number (Include Area Code). This is required whenever you provide a telephone number and must consist of exactly three numeric digits.

Enter your email address. This field is optional; leave it blank if you do not have an email address. Provide a valid email in standard format (for example, [email protected]).

Enter the location of the police report if it is known. This information can help support your claim by providing official documentation of the event.

Provide details of any other reports related to the traumatic event, such as After Action Reports, incident reports, formal complaints, or reports from legal or investigative services.

Select the appropriate option from the radio button list.

Select the appropriate option from the radio button list.

Select the appropriate option from the list provided.

Select the appropriate option from the list provided.

Check this box if you had pregnancy tests around the time of the traumatic event(s).

Check this box if you had tests for sexually transmitted infections.

Enter the 2-digit month when the last VA Form 21-22 or VA Form 21-22A was submitted, if known.

Use this section to provide any additional information that may support your claim. This section is optional and can be left blank.

Enter the accreditation number of the representative.

Provide the signature of the veteran or service member.

Enter the 2-digit month when the form was signed.

Enter the 2-digit day when the form was signed.

Enter the 4-digit year when the form was signed.

Enter the 2-digit month when the form was signed.

Enter the 2-digit day when the form was signed.

Enter the 4-digit year when the form was signed.

Enter the 2-digit day when the form was signed.

Enter the 4-digit year when the form was signed.

Provide the signature of the alternative signer.

Provide the signature of the POA/Authorized Representative.

Check this box if you have evidence from a Rape Crisis Center or Center for Domestic Abuse that can support your claim.

Check this box if you have evidence from a Counseling Facility or Health Clinic that can support your claim.

Check this box if you have statements or evidence from family members or roommates that can support your claim.

Check this box if you have evidence or statements from a faculty member that can support your claim.

Indicate if you have civilian police reports that support your claim of a traumatic event.

Indicate if you have medical reports from civilian physicians or caregivers who treated you immediately following the incident or sometime later.

Indicate if you have a statement or report from a chaplain or clergy that supports your claim.

Indicate if you have statements from fellow service members that support your claim of a traumatic event.

Indicate if you have personal diaries or journals that document the traumatic event.

Select this option if none of the listed types of evidence apply to your situation.

Select this option if you have other types of evidence not listed, and specify them in the space provided below.

Provide details of any other types of evidence you have that support your claim, if you selected 'Other' above.

Enter a concise summary of the first in-service traumatic event you experienced. Describe the nature of the event (for example, injury in warfare, physical assault, sexual harassment, witnessed death). Do not include location or dates (use 9B. LOCATION OF THE TRAUMATIC EVENT(S) and 9C. DATE(S) THE TRAUMATIC EVENT(S) OCCURRED for those details). Complete this field if you selected a traumatic event type in 8. SELECT THE TYPE OF IN-SERVICE TRAUMATIC EVENT(S) YOU EXPERIENCED. Use Section V: Remarks if additional space is needed.

Enter a concise summary of the nature of the second in-service traumatic event you experienced (e.g., injury in warfare, physical assault, sexual harassment, witnessing death or injury of a person). Complete this field only if you are reporting a second traumatic event; otherwise leave it blank. No special formatting is required. Provide related information in 9B. LOCATION OF THE TRAUMATIC EVENT(S) and 9C. DATE(S) THE TRAUMATIC EVENT(S) OCCURRED.

Enter a concise summary of the nature of your third in-service traumatic event (e.g., combat injury, physical assault, sexual harassment, witnessing death or injury of a person). This field is optional; complete only if you are providing details for a third event. Use plain text with no special formatting. If additional space is needed, use Section V: “Remarks.”

Enter the month(s) and year(s) when the first traumatic event occurred. Provide exact dates if known (for example, June 2007) or approximate dates if not (for example, Summer of ’70). Required when you have completed “Brief Description of the Traumatic Event(s)” (Item 9A) and “Location of the Traumatic Event(s)” (Item 9B) for the first event.

Enter the month(s) and year(s), or approximate dates, when the second traumatic event described in "9A. Brief Description of the Traumatic Event(s)" occurred (e.g., June 2007 or Summer ’70). If exact dates are unknown, provide approximate dates. This field is optional if dates cannot be determined.

Enter the month(s) and/or year(s) when the third in-service traumatic event occurred, as described in 9A. BRIEF DESCRIPTION OF THE TRAUMATIC EVENT(S) and located in 9B. LOCATION OF THE TRAUMATIC EVENT(S). If you do not know the exact dates, provide approximate dates or general time periods (for example, “JUNE 2007,” “SUMMER OF ’70,” or “BOOT CAMP”). Leave blank if you cannot determine any dates.

Enter the location where the second in-service traumatic event occurred, such as unit assignment, residence, off-base location, duty station, or state (e.g., “Fort XYZ, NC”). Provide a concise free-text description. Complete this field only if you are reporting a second event in Section II: Traumatic Event(s) Information.

Enter the location where the third in-service traumatic event occurred. Provide details such as unit assignment, duty station, off-base site, residence, state, or country; if you do not know the exact location, an approximate description is acceptable. Complete this field only when you are detailing a third traumatic event in Item 9B. LOCATION OF THE TRAUMATIC EVENT(S).

Provide a brief description of the traumatic event(s), such as injury in warfare, physical assault, sexual harassment, or witnessing the death or injury of a person.

Provide the location where the traumatic event occurred, such as unit assignment, residence, off-base, duty station, or state.

Enter the date or approximate date when the traumatic event occurred. You can provide the month(s) or year(s) if exact dates are not known.

Enter the date or approximate date(s) when the traumatic event(s) occurred. You can provide month(s) or year(s) if exact dates are not known.

Specify the location where the traumatic event(s) took place. This could include unit assignment, residence, off-base, duty station, or state, if known.

Provide a brief description of the traumatic event(s) you experienced, such as injury in warfare, physical assault, or witnessing the death or injury of a person.

Enter the date(s) when the traumatic event(s) occurred. You can provide month(s), year(s), or approximate dates if exact dates are unknown.

Specify the location where the traumatic event(s) occurred, such as unit assignment, residence, off-base, duty station, or state.

Provide a brief description of the traumatic event(s) you experienced, such as injury in warfare, physical assault, or witnessing the death or injury of a person.

Select this option if it applies to your situation. This is part of a series of radio buttons where you need to choose the most relevant option.

Select this option if it applies to your situation. This is part of a series of radio buttons where you need to choose the most relevant option.

Select this option if it applies to your situation. This is part of a series of radio buttons where you need to choose the most relevant option.

Select this option if it applies to your situation. This is part of a series of radio buttons where you need to choose the most relevant option.

Select this option if it applies to your situation. This is part of a series of radio buttons where you need to choose the most relevant option.

Check this box if you experienced one or more traumatic events while engaged in combat during your military service.

Check this box if you experienced a personal in-service traumatic event that did not involve military sexual trauma (MST).

Check this box when you experienced a personal in-service traumatic event that involved military sexual trauma.

Check this box if you experienced an in-service traumatic event that does not fall under combat or personal traumatic event categories.

Complete this field when you have entered a brief description in 9A. Brief Description of the Traumatic Event(s) for the first event. Enter the location where that event occurred (for example, unit assignment, residence, off-base location, duty station, state, or other place). No special formatting is required; approximate descriptions are acceptable if exact details are unknown.

Indicate if you have received treatment from a private healthcare provider, including non-Federal records.

Indicate if you have received treatment at a VA Vet Center.

Indicate if you have received community care that was paid for by the VA.

Check this box if you received treatment at a VA Medical Center or Community-Based Outpatient Clinic.

Check this box if you received treatment at a Department of Defense Military Treatment Facility.

Check this box if you do not have the dates of treatment available.

Enter the year of your treatment in a 4-digit format.

Enter the month of your treatment in a 2-digit format.

Enter the name and location of the treatment facility where you received care. This is the first line of the address.

Enter the name and location of the treatment facility where you received care. This is the second line of the address.

Enter the name and location of the treatment facility where you received care. This is the third line of the address.

Check this box if you do not have the dates of treatment available for the claimed condition.

Enter the 4-digit year of the treatment date for the claimed condition.

Enter the 2-digit month of the treatment date for the claimed condition.

Check this box if you do not have the dates of treatment available for the claimed condition.

Enter the 4-digit year of the treatment date for the claimed condition.

Enter the 2-digit month of the treatment date for the claimed condition.

Enter the veteran/service member’s first (given) name exactly as it appears on official records. Required. Use alphabetic characters only; do not include middle initial or last name.

Enter the numeric file number assigned by the Department of Veterans Affairs, exactly as it appears on your VA correspondence, without spaces or hyphens. This field is optional; if you do not have a VA File Number, leave it blank.

Enter the veteran or service member’s last name. Print each letter in a separate box, neatly and legibly in ink if completing by hand. This field is required.

Enter the veteran’s middle name initial as a single uppercase letter. If the veteran does not have a middle name, leave this field blank.

Enter the service number assigned to you during military service exactly as it appears on your service records, including any letters, numbers, or hyphens. This field is optional; leave it blank if you were not assigned a service number.

Enter the two middle digits of your Social Security Number (the group number). Input exactly two numeric digits with no spaces or hyphens (for example, if your SSN is 123-45-6789, enter 45). Required.

Enter the first three digits of the veteran’s nine-digit Social Security Number as shown on their Social Security card. Input exactly three numeric digits (no letters, hyphens, or spaces). This field is required for 2. SOCIAL SECURITY NUMBER.

Enter the last four digits of your Social Security Number. This field is required. Use only numeric characters, without dashes.

Enter the two-digit month in which you were born (01–12). Include a leading zero for January through September (for example, 03 for March). Required. See Date of Birth (MM/DD/YYYY).

Enter the day component of your Date of Birth (MM/DD/YYYY) using two digits (DD). Include a leading zero for single-digit days (for example, 07). This field is required.

Enter the four-digit year of your birth in YYYY format. Required to complete the Date of Birth (MM/DD/YYYY) entry.

Enter the printed name and address of the witness.

Enter the printed name and address of the witness.

Enter the 2-digit month when the witness signed the form.

Enter the 2-digit day when the witness signed the form.

Enter the 4-digit year when the witness signed the form.