Form VA Form 21-0773 VA Form 21-0773 Operation Enduring Freedom/Operation Iraqi Freedom Serio

OMB Approved No. 2900-xxxx
Respondent Burden: 30 minutes

OPERATION ENDURING FREEDOM/OPERATION IRAQI FREEDOM
SERIOUSLY INJURED/ILL SERVICEMEMBER/VETERAN WORKSHEET
IMPORTANT - Please read the Privacy Act and Respondent Burden Information on reverse before completing this form.
1A. LAST NAME-FIRST NAME-MIDDLE NAME

2. DATE OF BIRTH (Mo, day, year)

3. SOCIAL SECURITY NUMBER

4. PERMANENT MAILING ADDRESS (Street, City, State and ZIP Code)

5A. INJURY/ILLNESS

5B. REASON

VSI

SPC

SI

NSI

ILLNESS

BATTLE INJURY

NON BATTLE INJURY
5C. TELEPHONE NUMBER (Include area code) 5D. CELL PHONE NUMBER

6. BRANCH OF SERVICE
ARMY

7. THEATRE/OPERATION
COAST
GUARD

AIR FORCE

8. DATE RELEASED FROM ACTIVE DUTY

OIF

OEF

NAVY
MARINE CORP
OTHER
9A. NAME AND ADDRESS OF MILITARY/VA HOSPITAL (Street, City, State
and ZIP Code)

9B. ADMISSION DATE

10A. NAME OF NEXT OF KIN AND RELATIONSHIP

10B. ADDRESS OF NEXT OF KIN (Street, city, State and ZIP Code)

10C. TELEPHONE NUMBER OF NEXT OF KIN (Include Area Code)

10D. CELL PHONE NUMBER OF NEXT OF KIN (Include Area Code)

11. DATE OF INITIAL VA CONTACT

9C. WARD ROOM NUMBER

12A. NAME OF VA CONTACT PERSON

12B. TELEPHONE NO. OF VA CONTACT PERSON
(Include Area Code)

NOTE: Check all types that apply.
13. CLAIMS
CHECK

TYPE

14. SUPPORTING DOCUMENTS
DATE FILED

CHECK

TYPE

VA FORM 21-526 COMPENSATION AND PENSION

DD 214 SEPARATION DOCUMENT

VA FORM 21-4502 AUTOMOBILE GRANT

MARRIAGE CERTIFICATE

VA FORM 21-686C STATUS OF DEPENDENTS

BIRTH CERTIFICATE (S)

VA FORM 21-674C DEP. CHILD 18 OR OVER
VA FORM 21-509 DEPENDENT PARENT

DIVORCE DECREE (S)

CHECK

TYPE

VA FORM 22-1990 EDUCATION

VCAA

VA FORM 22- 5490 CH. 35 DEA

STRS

CURRENT

COMPLETE

MEB

VA FORM 26-1880 LOAN GUARANTY ELIGIBILITY
VA FORM 26-4555 ADAPTIVE HOUSING

PEB

VA FORM 26-8937 VERIFICATION OF VA BENEFITS

PERCENT %
TYPE OF RETIREMENT/SEPARATION

VA FORM 28-1900 VOCATIONAL REHABILITATION
VA FORM 28-8832 COUNSELING

MEB/PEB DOCUMENT PACKET

VA FORM 29-4364 RH INSURANCE

OTHER (Specify)

15. REFERRALS

VA FORM 10-8678 CLOTHING ALLOWANCE
DD 1172 APPLICATION FOR ID CARD

DATE RECEIVED

CHECK

DATE REFERRED

TYPE

Traumatic Injury Proctection (TSGLI)

VHA SOCIAL WORKER

Veteran’s Group Life Insurance (VGLI)

VR&E

Servicemembers’ Goup Life Insurance (SGLI)

VR&E TESTING PACKET ISSUED

STATE OR LOCAL BENEFITS (Specify)

SERVICE ORGANIZATIONS

OTHER (Specify)

STATE VETERANS AFFAIRS
SSA

ROJ
TRANSITION PATIENT ADVOCATE
FEDERAL RECOVERY COORDINATOR
OTHER (Specify)
VA FORM
JAN 2008

21-0773

Continued on Reverse

16A. LAST - FIRST - MIDDLE NAME

16B. LAST 4 OF SOCIAL SECURITY NUMBER

16C. CONTACTS, SERVICE PROVIDED, OTHER INFORMATION, AND DATE FOR FUTURE VISIT/COMMUNICATION
DATE

DESCRIPTION

INITIALS

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 the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and
Rehabilitation Records - VA, and published in the Federal Register. Your obligation to respond is voluntary. The VA will not deny an individual benefits for refusing to provide
his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect Prior to January 1, 1975, and still in effect.
RESPONDENT BURDEN: This form will be used as a checklist to ensure Veterans Service Representatives are providing OEF/OIF Seriously Injured/Ill
Servicemembers/veterans with information and/or forms for all VA benefits, in addition to SSA, State and local benefits. Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 30 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.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to
get information on where to send comments or suggestions about this form.