VA Form 21-0960I-6 Tuberculosis Disability Benefits Questionnaire

OMB Control No. 2900-XXXX
Respondent Burden: 30 minutes

TUBERCULOSIS 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.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH ACTIVE/LATENT TUBERCULOSIS (TB)?
YES

NO

(If "No," complete Items 1B, 1C and 1D)

(If "Yes," complete Item 1E)

1B. PROVIDE RATIONALE/REASON (e.g., veteran does not currently have any known TB condition(s))

1C. HAS THE VETERAN HAD A POSITIVE SKIN TEST FOR TB WITHOUT ACTIVE DISEASE?
YES

NO

1D. HAS THE VETERAN HAD A POSITIVE QUANTIFERON-TB GOLD TEST WITHOUT ACTIVE DISEASE?
YES

NO

1E. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO TB CONDITIONS
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1F. IF ADDITIONAL DIAGNOSIS THAT PERTAIN TO TB, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S CURRENT TB CONDITION (brief summary)

2B. INDICATE TB CONDITION (check all that apply)
PULMONARY TB
NON-PULMONARY TB
2C. IS THE VETERAN UNDERGOING TREATMENT OR HAS HE OR SHE COMPLETED TREATMENT FOR A TB CONDITION, INCLUDING ACTIVE TB, POSITIVE
SKIN TEST OR LABORATORY EVIDENCE OF TB (positive quantiferon-TB gold test) WITHOUT ACTIVE DISEASE?
YES

NO

(If "Yes," complete the following)
(Date treatment began):
(If completed, date of completion):
(If not completed, anticipated date of completion):
(List medications used for treatment of TB condition):
SECTION III - PULMONARY TUBERCULOSIS
3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH PULMONARY TUBERCULOSIS?
YES

NO

(If "Yes," is the condition):
ACTIVE

INACTIVE

(If inactive, date condition became inactive)
VA FORM
DEC 2010

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SECTION III - PULMONARY TUBERCULOSIS (Continued)
3B. DOES THE VETERAN HAVE ANY RESIDUAL FINDINGS, SIGNS AND/OR SYMPTOMS DUE TO PULMONARY TUBERCULOSIS?
YES

NO

(If "Yes," indicate residuals) (Check all that apply)
Emphysema
Dyspnea on exertion
Requires oxygen therapy
Episodes of acute respiratory failure
Moderately advanced lesions
Far advanced lesions (diagnosed at any time while the disease process was active)
Pulmonary hypertension
Right ventricular hypertrophy
Cor pulmonale (right heart failure)
Impairment of health
Other, describe:
3C. HAS THE VETERAN HAD THORACOPLASTY DUE TO TB?
YES

NO

(If "Yes," date of procedure):
(If "Yes," has the veteran had resection of any ribs incident to thoracoplasty?)
YES

NO

(If "Yes," indicate number of ribs involved)

1

2

3 or 4

5 or 6

More than 6

SECTION IV - NON-PULMONARY TUBERCULOSIS
4A. DOES THE VETERAN HAVE ANY OF THE FOLLOWING NON-PULMONARY TB CONDITIONS?
YES

NO

(If "Yes," check all that apply)
Tuberculous pleurisy
Tuberculous peritonitis
Tuberculosis meningitis
Skeletal TB
Genitourinary TB
Gastrointestinal TB
Tuberculous lymphadenitis
Cutaneous TB
Ocular TB
Other, describe:
4B. FOR ALL CONDITIONS CHECKED IN ITEM 4A, INDICATE WHETHER THE CONDITION IS ACTIVE OR INACTIVE, AND IF INACTIVE, THE DATE CONDITION
BECAME INACTIVE

4C. DOES THE VETERAN HAVE ANY RESIDUALS FROM ANY OF THE NON-PULMONARY TB CONDITIONS CHECKED IN ITEM 4A?
YES

NO (If "Yes," describe and also complete the appropriate questionnaire(s) for the specific condition)

SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
5. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES

NO (If "Yes," describe (brief summary):

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SECTION VI - DIAGNOSTIC TESTING

NOTE: If pulmonary function testing (PFT) is indicated, and results are in the medical record and reflect the veteran's current
respiratory function, repeat testing is not required.
6A. HAVE PFTs BEEN PERFORMED?
YES

NO

(If "Yes," provide most recent results, if available)
FEV 1:

% predicted

Date of test:
% predicted

FEV 1 post bronchodilator, if indicated/performed:
% predicted

FEV 1/FVC:

% predicted

FEV 1/FVC post bronchodilator, if indicated/performed:
% predicted

FVC :

Date of test:

Date of test:
Date of test:

Date of test:

DLCO (Diffusion capacity of the lung for carbon monoxide):

% predicted

Date of test:

(If post-bronchodilator testing was not conducted, provide an explanation of why not)
Post-bronchodilator testing is not indicated for the veterans condition
Other reason:
NOTE: POST-BRONCHODILATOR TESTING IS ONLY INDICATED FOR PULMONARY CONDITIONS WHICH MAY BE RESPONSIVE TO BRONCHODILATORS.
NOTE: FOR OBSTRUCTIVE LUNG CONDITIONS, FEV1 MOST ACCURATELY REFLECTS THE SEVERITY OF THE CONDITION. FOR RESTRICTIVE LUNG
CONDITIONS, FVC MOST ACCURATELY REFLECTS THE SEVERITY OF THE CONDITION.
6B. DOES THE VETERAN HAVE MULTIPLE PULMONARY DIAGNOSES?
YES

NO

(If "Yes," list multiple pulmonary diagnoses):
(If there are multiple pulmonary diagnoses, is it possible to differentiate the PFT results that represent conditions other than pulmonary TB from those that reflect
the veteran's pulmonary condition due to pulmonary TB?)
YES

NO

(If "Yes," differentiate contribution of each condition diagnosed to overall PFT results):
(If "No," explain why it is not possible to differentiate PFT results by specific condition):
6C. HAVE A CHEST X-RAY, CT SCAN AND/OR OTHER DIAGNOSTIC IMAGING STUDIES BEEN PERFORMED?
YES

NO

(If "Yes," provide results):

Date(s) of test(s):

6D. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

(If "Yes," provide type of test or procedure, date and results (brief summary)):
SECTION VII - FUNCTIONAL IMPACT
7. DOES THE VETERAN'S TUBERCULOSIS CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact of each of the veteran's tuberculosis condition(s), providing one or more examples)

SECTION VIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
8A. PHYSICIAN'S SIGNATURE
8D. PHYSICIAN'S PHONE NUMBER

8B. PHYSICIAN'S PRINTED NAME
8E. PHYSICIAN'S MEDICAL LICENSE NUMBER

8C. DATE SIGNED
8F. 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 30
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 21-0960I-6, DEC 2010

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