Form VA Form 21-0819 VA Form 21-0819 VA/DOD Joint Evaluation Board Claim

OMB Approved No. 2900-0704
Respondent Burden: 30 minutes

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

VA/DOD JOINT DISABILITY EVALUATION BOARD CLAIM
IMPORTANT - Please read the Privacy Act and Respondent Burden on the back
before completing the form.
Section I: To be completed by Military Treatment Facility referring service member to Disability Evaluation Section
SERVICE MEMBER NAME (First, middle, last)

GRADE

COMPONENT

UNIT ADDRESS

SOCIAL SECURITY NUMBER

DATE OF BIRTH (MM,DD,YYYY)

NAME AND PHONE NUMBER OF ASSIGNED DISABILITY
EVALUATION BOARD LIAISON OFFICER (DEBLO)
Include Area Code
(First, MI, Last)

(

SEX

NAME OF REFERRING MILITARY TREATMENT
FACILITY (MTF)

MALE
FEMALE
DATE OF REFERRAL TO MEDICAL
EVALUATION BOARD (MEB) (MM,DD,YYYY)

)

WHAT IS YOUR ADDRESS?

WHAT ARE YOUR TELEPHONE NUMBERS?
(Include Area Code)

Street address, rural route, or P.O. Box

City

Apt. number

State

ZIP Code

Country

Daytime

(

)

Evening

(

)

Cell phone

(

)

WHAT IS YOUR E-MAIL ADDRESS (If applicable)

MEDICAL CONDITIONS TO BE CONSIDERED AS THE BASIS OF FITNESS FOR DUTY DETERMINATION (List only conditions referred by physician):

PREPARED BY

DATE PREPARED

Section II: Tell us about yourself.Please provide a contact name and address. If you are on Temporary Duty, please
indicate that on the VA Form 21-4138, Statement in Support of Claim available on the internet at www.va.gov/vaforms

1. Have you ever filed a claim with VA?

2. Point of contact name and address

No (If "Yes," provide file number)

Yes

(VA File Number)

3a. Did you serve under another name?
Yes

3b. Please list the other name(s) you served under

(If "Yes," go to Item 3b)

No (If "No," go to Item 4)
4. I entered this current period of active service on:
5. Place of entry:

mo

day

yr

Section III: Tell us about your military service. Enter complete information for your service.
Tell us about your reserve duty or National Guard Duty

6. Are you currently assigned to an
active reserve unit or National Guard Unit?
Yes

(If "Yes," provide date of
activation below)

No

7b. What is the telephone
number of your
current unit? (Include
Area Code)
(

mo
VA FORM
JUL 2007

7a. What is the name and mailing address
of your current unit?

21-0819

day

yr

)

8. Additional Conditions - (Do you have any disabling conditions, other than those referred for the fitness for duty
determination, that you feel were caused by, or aggravated by, your active military service?) Please list those
disabilities below:

Section IV: Give us your signature

I certify and authorize the release of information.
I certify that the statements in this document are true and complete to the best of my knowledge.
9. Your signature (Do NOT print)

10. Date signed

Section V: Witnesses to Signature

11a. Signature of Witness (If claimant signed above using an "X")

11b. Printed name and address of witness

12a. Signature of Witness (If claimant signed above using an "X")

12b. Printed name and address of witness

PRIVACY ACT NOTICE: The form will be used to determine allowance to compensation benefits (38 U.S.C. 5101). The responses you submit are considered confidential (38
U.S.C. 5701). VA may disclose the information that you provide, including Social Security numbers, outside VA if the disclosure is authorized under the Privacy Act, including
the routine uses identified in the VA system of records, 58VA21/22 Compensation, Pension, Education, and Rehabilitation Records - VA. The requested information is
considered relevant and necessary to determine maximum benefits under the law. Information submitted is subject to verification through computer matching programs with
other agencies. VA may make a "routine use" disclosure for: 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. Your obligation to respond is required in order to obtain or retain benefits. Information that you furnish may be
utilized in computer matching programs with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any
amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans Affairs. Social Security information:
You are required to provide the Social Security number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act,
and, specifically may disclose them for purposes stated above.
RESPONDENT BURDEN: We need this information to determine your eligibility for compensation. 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.