VA Form 21-0781a Statement in Support of Claim for Service Connection for

OMB Approved No. 2900- 0659
Respondent Burden: 1 hour 10 minutes
VA DATE STAMP
DO NOT WRITE IN THIS SPACE

STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION FOR
POST-TRAUMATIC STRESS DISORDER (PTSD) SECONDARY TO
PERSONAL ASSAULT
INSTRUCTIONS: List the stressful incident or incidents that occurred in service that you feel contributed to your current
condition. For each incident, provide a description of what happened, the date, the geographic location, your unit assignment and
dates of assignment. Please complete the form in detail and be as specific as possible so that research of military records and other
sources you identify can be thoroughly conducted. If more space is needed, attach a separate sheet, indicating the item number to
which the answers apply.
1. NAME OF VETERAN (First, Middle, Last)

2. VA FILE NO.

STRESSFUL INCIDENT NO. 1
3A. DATE INCIDENTOCCURRED (Mo., day, yr.)

3B. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)

3C. UNIT ASSIGNMENT DURING INCIDENT (SUCH AS, DIVISION, WING, BATTALION,
CALVARY, SHIP)

3D. DATES OF UNIT ASSIGNMENT (Mo., day, yr.)
FROM

TO

3E. DESCRIPTION OF THE INCIDENT

4. OTHER SOURCES OF INFORMATION: Identify any other sources (military or non-military) that may provide information
concerning the incident. If you reported the incident to military or civilian authorities or sought help from a rape crisis center,
counseling facility, or health clinic etc., please provide the names and addresses and we will assist you in getting the information. If
the source provided treatment and you would like us to obtain the treatment records, complete VA Form 21-4142, Authorization and
Consent to Release Information to the Department of Veterans Affairs (VA), for each provider. If you confided in roommates, family
members, chaplains, clergy, or fellow service persons, you may want to ask them for a statement concerning their knowledge of the
incident. These statements will help us in deciding your claim.
NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

VA FORM
OCT 2007

21-0781a

EXISTING STOCK OF VA FORM 21-0781A, JUL 2004,
WILL BE USED.

STRESSFUL INCIDENT NO. 2
6A. DATE INCIDENT OCCURRED (Mo.,day, yr.)

6B. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)

6C. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,
CALVARY, SHIP)

6D. DATES OF UNIT ASSIGNMENT(Mo.,day,yr.)
FROM

TO

6E. DESCRIPTION OF THE INCIDENT

7. OTHER SOURCES OF INFORMATION: Identify any other sources (military or non-military) that may provide information
concerning the incident. If you reported the incident to military or civilian authorities or sought help from a rape crisis center,
counseling facility, or health clinic etc., please provide the names and addresses and we will assist you in getting the information.
If the source provided treatment and you would like us to obtain the treatment records, complete VA Form 21-4142, Authorization
and Consent to Release Information to the Department of Veterans Affairs (VA), for each provider. If you confided in roommates,
family members, chaplains, clergy, or fellow service persons, you may want to ask them for a statement concerning their
knowledge of the incident. These statements will help us in deciding your claim.
NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

8. Please provide in the space below any other information that you feel is important for us to know that may help your claim. Let us
know if you experienced any of the following or other behavior changes following the incident(s):
visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment

substance abuse such as alcohol or drugs

sudden requests for a change in occupational series or duty assignment

increased disregard for military or civilian authority

increased use of leave without an apparent reason

obsessive behavior such as overeating or undereating

changes in performance and performance evaluations

pregnancy tests around the time of the incident

episodes of depression, panic attacks, or anxiety without an identifiable cause

tests for HIV or sexually transmitted diseases

increased or decreased use of prescription medications

unexplained economic or social behavior changes

increased use of over-the-counter medications

breakup of a primary relationship

I certify that the foregoing statement(s) are true and correct to the best of my knowledge and belief.
9. SIGNATURE

10. DATE

11. TELEPHONE NUMBERS (Include Area Code)
DAYTIME

EVENING

PENALTY - The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any statement or evidence of a material fact,
knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.

PRIVACY ACT NOTICE: The 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,
Compensation, Pension, Education and Rehabilitation Records - VA, published in the Federal Register. Your obligation to respond is
voluntary. However, the requested information is necessary to obtain supporting evidence of stressful incidents in service. If the
information is not furnished completely or accurately, VA will not be able to thoroughly research your military records and other
sources for supporting evidence. The responses you submit are considered confidential (38 U.S.C. 5701).
RESPONDENT BURDEN: We need this information in order to assist you in supporting your claim for post-traumatic stress
disorder (38 U.S.C. 5107 (a)). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an
average of 1 hour and 10 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.