VA Form 21-0960b Hairy Cell and Other B-Cell Leukemias Disability Benefit

OMB Approved No. 2900-XXXX
Respondent Burden: 15 minutes

HAIRY CELL AND OTHER B-CELL LEUKEMIAS
DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION ON REVERSE BEFORE COMPLETING
NAME OF PATIENT/VETERAN

PATIENT/VETERAN’S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - The veteran has applied to the Department of Veterans Affairs (VA) for disability benefits. Please complete this
questionnaire, which VA needs for review of the veteran’s application.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH HAIRY CELL LEUKEMIA OR ANY OTHER B-CELL LEUKEMIA?

(If "No," please skip to Section V)
YES
NO
1B. DIAGNOSIS (Give a brief description of the type of leukemia)

1C. DATE OF DIAGNOSIS

1D. STATUS OF DISEASE
ACTIVE

REMISSION

SECTION II - TREATMENT
2. TREATMENT (Check)
VETERAN IS CURRENTLY UNDERGOING TREATMENT FOR THIS LEUKEMIA WITH SURGICAL, RADIATION, IMMUNOTHERAPY,
ANTINEOPLASTIC CHEMOTHERAPY AND/OR OTHER THERAPEUTIC PROCEDURES
VETERAN HAS COMPLETED TREATMENT FOR THIS LEUKEMIA (Please provide date of discontinuance of treatment _____________________________________)

SECTION III - RESIDUAL COMPLICATIONS OF TREATMENT
3A. IF SIX MONTHS OR MORE HAVE PASSED SINCE DISCONTINUANCE OF LEUKEMIA TREATMENT, DOES THE PATIENT/VETERAN CURRENTLY HAVE ANY
RESIDUAL COMPLICATIONS?
YES

(If "Yes," please complete Item 3B below)

NO

3B. RESIDUAL COMPLICATIONS OF TREATMENT (Check all that apply)
RESIDUAL COMPLICATIONS REQUIRING TRANSFUSION OF PLATELETS OR RED CELLS:
AT LEAST ONCE EVERY SIX WEEKS
AT LEAST ONCE EVERY THREE MONTHS
AT LEAST ONCE PER YEAR BUT LESS THAN ONCE EVERY THREE MONTHS
RESIDUAL COMPLICATIONS CAUSING RECURRING INFECTIONS:
AT LEAST ONCE EVERY SIX WEEKS
AT LEAST ONCE EVERY THREE MONTHS
AT LEAST ONCE PER YEAR BUT LESS THAN ONCE EVERY THREE MONTHS
RESIDUAL COMPLICATIONS RELATED TO ANEMIA:
BONE MARROW TRANSPLANT DUE TO APLASTIC ANEMIA
ASYMPTOMATIC ANEMIA
SYMPTOMATIC ANEMIA (Check signs and symptoms that apply)
WEAKNESS

EASY FATIGABILITY

TACHYCARDIA

HIGH OUTPUT CONGESTIVE
HEART FAILURE

HEADACHES

SYNCOPE

CARDIOMEGALY

DYSPNEA ON MILD EXERTION

DYSPNEA AT REST

SHORTNESS OF BREATH

LIGHT-HEADEDNESS

REQUIRES CONTINUOUS USE OF MEDICATION FOR CONTROL OF ANEMIA:

OTHER SYMPTOM(S) (Specify __________________________
_____________________________________________________
YES

NO

IF ANEMIA IS PRESENT MOST RECENT HEMOGLOBIN LEVEL (gm/100ml): _____________________ Date___________________
3C. IF ANY OTHER RESIDUAL COMPLICATIONS ARE PRESENT PLEASE SPECIFY:

VA FORM
MAY 2010

21-0960B

SECTION IV - REMARKS
4. REMARKS (Including impact of leukemia on veteran’s ability to work)

SECTION V - PHYSICIAN’S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
5A. PHYSICIAN’S SIGNATURE

5D. PHYSICIAN’S PHONE NUMBER

5B. PHYSICIAN’S PRINTED NAME

5E. PHYSICIAN’S MEDICAL LICENSE NUMBER

5C. DATE SIGNED

5F. PHYSICIAN’S ADDRESS

NOTE - VA may obtain additional medical information, including an examination, if necessary to complete VA’s
review of the veteran’s application.
IMPORTANT - Physician please fax the completed form to _________________________________________
(VA Regional Office FAX No.)
PRIVACY ACT NOTICE: 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 Vocational
Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. VA uses your SSN to
identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary.
Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure
of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to
determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through
computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information.
We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete a 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.
VA FORM MAY 2010, 21-0960B