VA Form 21-0960P-3 Review Post Traumatic Stress ( PTSD) Disability Benefits

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

REVIEW POST TRAUMATIC STRESS (PTSD)
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 THIS FORM.
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NAME OF PATIENT/VETERAN

IMPORTANT - If the veteran experiences a mental health emergency during the interview, please terminate the interview and obtain help, using local
resources as appropriate. You may also contact the VA Suicide Prevention Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the veteran to
emergency care.
NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you
provide on this questionnaire as part of their evaluation in processing the veteran's claim.

CRITERIA INFORMATION FOR PTSD EXAMINER
IMPORTANT: In order to conduct an initial examination for PTSD, the examiner must meet one of the following criteria: (1) be a board-certified or board-eligible
psychiatrist; (2) a licensed doctorate-level psychologist; (3) a doctorate-level mental health provider under the close supervision of a board-certified or board-eligible
psychiatrist or licensed doctorate-level psychologist; (4) a psychiatry resident under close supervision of a board-certified or board-eligible psychiatrist or licensed
doctorate-level psychologist; (5) or a clinical or counseling psychologist completing a one-year internship or residency (for purposes of a doctorate-level degree) under
close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist.
In order to conduct a REVIEW examination for PTSD, the examiner must meet one of the criteria from above, OR be a licensed clinical social worker (LCSW), a nurse
practitioner, a clinical nurse specialist, or a physician assistant, under close supervision of a board-certified or board-eligible
psychiatrist or doctorate-level psychologist.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE A DIAGNOSIS OF PTSD THAT CONFORMS TO DSM IV CRITERIA?
NO (If "Yes," complete Item1B) (If "No," complete Item 1C)

YES

1B. PROVIDE THE DATE OF DIAGNOSIS, ICD CODE, & FACILITY)
ICD CODE-

NAME OF DIAGNOSING FACILITY OR CLINICIAN

DATE OF DIAGNOSIS

1C. IF PTSD NOT DIAGNOSED (Check all that apply)
VETERAN'S SYMPTOMS DO NOT MEET THE DIAGNOSTIC CRITERIA FOR PTSD UNDER DSM IV CRITERIA
VETERAN HAS ANOTHER AXIS I DIAGNOSIS (If checked, list the Axis I diagnoses and then complete the VA Form 21-0960P-2, Mental Health Disorder Disability Benefits
Questionnaire and/or the VA Form 21-0960P-1, Eating Disorder Disability Benefits Questionnaire in lieu of this questionnaire):
OTHER TRAUMA SPECTRUM DISORDER
VETERAN DOES NOT HAVE A MENTAL DISORDER THAT CONFORMS WITH DSM IV CRITERIA
OTHER (Describe)
1D. IF THERE IS A DIAGNOSIS OF PTSD, DOES THE VETERAN ALSO HAVE A NY OTHER AXIS I-IV DIAGNOSES?
YES

NO (If "Yes," indicate additional diagnoses below)
MENTAL HEALTH DISORDER #

(If checked, provide the ICD code
clinician
(If checked, indicate the Axis category):

, the date of the diagnosis

AXIS I

AXIS II

AXIS III

and the name of the diagnosing facility or

AXIS IV

(If checked, describe the condition and its relationship to PTSD):
MENTAL HEALTH DISORDER #
(If checked, provide the ICD code
clinician
(If checked, indicate the Axis category):

, the date of the diagnosis

AXIS I

AXIS II

AXIS III

and the name of the diagnosing facility or

AXIS IV

(If checked, describe the condition and its relationship to PTSD):
MENTAL HEALTH DISORDER #
(If checked, provide the ICD code
clinician
(If checked, indicate the Axis category):

, the date of the diagnosis

AXIS I

AXIS II

AXIS III

and the name of the diagnosing facility or

AXIS IV

(If checked, describe the condition and its relationship to PTSD):
(If additional diagnoses, describe, using the above format):

VA FORM
DEC 2010

21-0960P-3

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SECTION II - DIAGNOSTIC CRITERIA
2. THE DIAGNOSTIC CRITERIA FOR PTSD, REFERRED TO AS CRITERIA A - F, ARE FROM THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS 4TH EDITION (DSM-IV) (Check boxes next to symptoms below)

CRITERION A: The Veteran has been exposed to a traumatic event where both of the following were present
Veteran experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of
self or others
Veteran's response involved intense fear, helplessness or horror
No exposure to a traumatic event

CRITERION B: The traumatic event is persistently reexperienced in 1 or more of the following ways:
Recurrent and distressing recollections of the event, including images, thoughts or perceptions
Recurrent distressing dreams of the event
Acting or feeling as if the traumatic event were recurring; this includes a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes,
including those that occur on awakening or when intoxicated
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
The traumatic event is not persistently reexperienced

CRITERION C: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness
(not present before the trauma), as indicated by 3 or more of the following:
Efforts to avoid thoughts, feelings or conversations associated with the trauma
Efforts to avoid activities, places or people that arouse recollections of the trauma
Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant activities
Feeling of detachment or estrangement from others
Restricted range of affection (e.g., unable to have loving feelings)
Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children or a normal life span)
No persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness

CRITERION D: Persistent symptoms of increased arousal, not present before the trauma, as indicated by 2 or more of the following:
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilence
Exaggerated startle response
No persistent symptoms of increased arousal

CRITERION E: Duration of symptoms
The duration of the symptoms described in Criteria B, C and D is more than 1 month
The duration of the symptoms described in Criteria B, C and D is less than 1 month
No symptoms

CRITERION F: Clinically significant distress or impairment
The symptoms described above in Criteria B, C and D cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
The symptoms described above in Criteria B, C and D do NOT cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning
No symptoms

VA FORM 21-0960P-3, DEC 2010

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SECTION III - SYMPTOMS
3. SYMPTOMS - FOR EACH LEVEL BELOW, CHECK ALL SYMPTOMS THAT APPLY. CONSIDER THE CUMULATIVE IMPACT OF ALL DIAGNOSED MENTAL
DISORDERS THAT THE EXAMINER JUDGES RELATED TO MILITARY SERVICE, WITHOUT ATTEMPTING TO DIFFERENTIATE WHICH SYMPTOMS ARE
SPECIFICALLY CAUSED BY WHICH MENTAL DISORDER
A. LEVEL I Has the veteran been diagnosed with PTSD (and/or other mental disorder), but symptoms are not severe enough either to interfere with occupational and social functioning or to
require continuous medications?
YES
NO
B. LEVEL II Does the veteran have occupational and social impairment due to mild or transient symptoms, which decrease work efficiency and ability to perform occupational tasks only
during periods of significant stress, or are the veteran's symptoms controlled by continuous medication?
YES

NO

C. LEVEL III Does the veteran have any symptoms from the list below?
YES

NO (If "Yes," check all that apply)
Depressed mood
Anxiety
Suspiciousness
Panic attacks that occur weekly or less often
Chronic sleep impairment
Mild memory loss, such as forgetting names, directions or recent events

D. LEVEL IV Does the veteran have any symptoms from the list below?
YES

NO (If "Yes," check all that apply)
Flattened affect
Circumstantial, circumlocutory or stereotyped speech
Panic attacks more than once a week
Difficulty in understanding complex commands
Impairment of short - and long - term memory, for example, retention of only highly learned material, while forgetting to complete tasks
Impaired judgment
Impaired abstract thinking
Disturbances of motivation and mood
Difficulty in establishing and maintaining effective work and social relationships

E. LEVEL V Does the veteran have any symptoms from the list below?
YES

NO (If "Yes," check all that apply)
Suicidal ideation
Obsessional rituals which interfere with routine activities
Speech intermittently illogical, obscure, or irrelevant
Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively
Impaired impulse control, such as unprovoked irritability with periods of violence
Spatial disorientation
Neglect of personal appearance and hygiene
Difficulty in adapting to stressful circumstances, including work or a worklike setting
Inability to establish and maintain effective relationships

F. LEVEL VI Does the veteran have any symptoms from the list below?
YES

NO (If "Yes," check all that apply)
Gross impairment in thought processes or communication
Persistent delusions or hallucinations
Grossly inappropriate behavior
Persistent danger of hurting self or others
Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene
Disorientation to time or place
Memory loss for names of close relatives, own occupation, or own name

VA FORM 21-0960P-3, DEC 2010

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SECTION III - SYMPTOMS (Continued)
3G. DOES THE VETERAN HAVE ANY OTHER SYMPTOMS ATTRIBUTABLE TO PTSD (and/or other mental disorder) THAT ARE NOT LISTED ON PAGE 3?
YES

NO

(If "Yes," describe):

SECTION IV - OCCUPATIONAL AND SOCIAL IMPAIRMENT
4. WHICH OF THE FOLLOWING BEST REPRESENTS THE VETERAN'S LEVEL OF OCCUPATIONAL AND SOCIAL IMPAIRMENT?
A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require
continuous medication
Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of
significant stress, or symptoms controlled by medication
Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally
functioning satisfactorily, with normal routine behavior, self-care and conversation
Occupational and social impairment with reduced reliability and productivity
Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood
Total occupational and social impairment

SECTION V - GLOBAL ASSESSMENT OF FUNCTIONING (GAF)
5. PROVIDE THE CURRENT GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCORE

SECTION VI - COMPETENCY
6. IS THE VETERAN CAPABLE OF MANAGING HIS OR HER FINANCIAL AFFAIRS?
YES

NO

(If "No," explain):

SECTION VII - FUNCTIONAL IMPACT AND REMARKS
7. DOES THE VETERAN'S PTSD AND/OR OTHER MENTAL DISORDER(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact, providing one or more examples)

8. REMARKS (If any)

SECTION VIII - PSYCHIATRIST/PSYCHOLOGIST CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
9A. PSYCHIATRIST/PSYCHOLOGIST SIGNATURE AND TITLE

9D. PSYCHIATRIST/PSYCHOLOGIST PHONE NUMBER

9B. PSYCHIATRIST/PSYCHOLOGIST PRINTED NAME

9E. PSYCHIATRIST/PSYCHOLOGIST LICENSE NUMBER

9C. DATE SIGNED

9F. PSYCHIATRIST/PSYCHOLOGIST ADDRESS

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

IMPORTANT - PSYCHIATRIST/PSYCHOLOGIST send 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 21-0960P-3, DEC 2010

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