VA Form 21-0960I-1 Persian Gulf and Afghanistan Infectious Diseases Disabil

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

PERSIAN GULF AND AFGHANISTAN INFECTIOUS DISEASES
DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE
PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION
BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will use the information you provide
on this questionnaire to process the Veteran's claim.
IMPORTANT - This questionnaire is intended solely for claims based on 38 CFR 3.317(c) Presumptive Service Connection or Infectious Disease.
Therefore, this questionnaire should only be completed for veterans who have or have had one or more of the following diseases: Brucellosis, Campylobacter jejuni,
Coxiella burnetii (Q fever), malaria, Mycobacterium tuberculosis, Nontyphoid Salmonella, Shigella, Visceral leishmaniasis and West Nile virus.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH ANY OF THE INFECTIOUS CONDITION(S) LISTED ABOVE?
YES

NO

(If "No," complete Item 1B)

(If "Yes," complete Item 1C)

1B. PROVIDE RATIONALE / REASON (e.g., veteran has never had any of the infectious condition(s) listed above)

1C. INFECTIOUS DISEASE(S) THAT THE VETERAN NOW HAS OR HAS BEEN DIAGNOSED WITH (Check all that apply)
BRUCELLOSIS

ICD CODE:

DATE OF DIAGNOSIS:

CAMPYLOBACTER JEJUNI

ICD CODE:

DATE OF DIAGNOSIS:

COXIELLA BURNETII (Q FEVER)

ICD CODE:

DATE OF DIAGNOSIS:

MALARIA

ICD CODE:

DATE OF DIAGNOSIS:

NONTYPHOID SALMONELLA

ICD CODE:

DATE OF DIAGNOSIS:

SHIGELLA

ICD CODE:

DATE OF DIAGNOSIS:

VISCERAL LEISHMANIASIS

ICD CODE:

DATE OF DIAGNOSIS:

WEST NILE VIRUS
ICD CODE:
MYCOBACTERIUM TUBERCULOSIS (TB) ICD CODE:
(If TB is the only diagnosis checked, do not
complete the rest of this questionnaire; instead
complete VA Form 21-0960I-6, Tuberculosis
Disability Benefits Questionnaire)

DATE OF DIAGNOSIS:
DATE OF DIAGNOSIS:

NOTE: If any other disease(s) have been checked along with mycobacterium tuberculosis, complete the Tuberculosis Disability Benefits Questionnaire, VA Form
21-0960I-6 for all tuberculosis-related conditions, and also complete this questionnaire VA Form 21-0960I-1 for all other non-tuberculosis related diseases checked
above.
SECTION II - MEDICAL HISTORY FOR INFECTIOUS DISEASE(S)
2A. PROVIDE THE NAME OF DISEASE # 1 AND GIVE A DESCRIPTION AND HISTORY (including onset and course) (brief summary):

2B. STATUS OF DISEASE # 1
ACTIVE
INACTIVE/TREATED AND RESOLVED
(If inactive, date disease became inactive/resolved)
(If inactive/resolved, are there residuals due to the disease?)
NO
YES
(If "Yes," describe residuals):
(If "Yes," also complete appropriate questionnaire for each specific residual condition, if indicated)
3A. PROVIDE THE NAME OF DISEASE # 2 AND GIVE A DESCRIPTION AND HISTORY (including onset and course) (brief summary):

3B. STATUS OF DISEASE # 2
ACTIVE

INACTIVE/TREATED AND RESOLVED
(If inactive, date disease became inactive/resolved)
(If inactive/resolved, are there residuals due to the disease?)
YES

NO

(If "Yes," describe residuals):
(If "Yes," also complete appropriate questionnaire for each specific residual condition, if indicated)
VA FORM
DEC 2010

21-0960I-1

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SECTION II - MEDICAL HISTORY FOR INFECTIOUS DISEASE(S) (Continued)
4A. PROVIDE THE NAME OF DISEASE # 3 AND GIVE A DESCRIPTION AND HISTORY (including onset and course) (brief summary):

4B. STATUS OF DISEASE # 3
ACTIVE

INACTIVE/TREATED AND RESOLVED
(If inactive, date disease became inactive/resolved)
(If inactive/resolved, are there residuals due to the disease?)
YES

NO

(If "Yes," describe residuals):
(If "Yes," also complete appropriate questionnaire for each specific residual condition, if indicated)
5. IF THERE ARE ADDITIONAL GULF WAR INFECTIOUS DISEASES, DESCRIBE USING ABOVE FORMAT

SECTION III - DIAGNOSTIC TESTING

NOTE: If the veteran has had diagnostic testing for suspected or confirmed Gulf War infectious diseases and the results are in the medical record and
reflect the veteran's current status, repeat testing is not indicated.
6. ARE THERE ANY SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO (If "Yes," provide type of test or procedure, date and results (brief summary):

SECTION IV - FUNCTIONAL IMPACT AND REMARKS
7. DOES THE VETERAN'S GULF WAR INFECTIOUS CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO (If "Yes," describe impact of each of the veteran's Gulf War infectious condition(s), providing one or more examples)

8. REMARKS (If any)

SECTION V - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
9A. PHYSICIAN'S SIGNATURE
9D. PHYSICIAN'S PHONE NUMBER

9B. PHYSICIAN'S PRINTED NAME
9E. PHYSICIAN'S MEDICAL LICENSE NUMBER

9C. DATE SIGNED
9F. 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.)
NOTE - A list of VA Regional Office FAX Numbers can be found at www.vba.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
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, 58/VA21/22/28, 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 the 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.

VA FORM DEC 2010, 21-0960I-1

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