VA Form 21-0960C-5 Central Nervous System and Neuromusculo Diseases Disabil

OMB Approved No. 2900-XXXX
Respondent Burden: 30 minutes
CENTRAL NERVOUS SYSTEM AND NEUROMUSCULAR DISEASES
(EXCEPT TRAUMATIC BRAIN INJURY, AMYOTROPHIC LATERAL SCLEROSIS, PARKINSON’S
DISEASE, MULTIPLE SCLEROSIS, HEADACHES, TMJ CONDITIONS, EPILEPSY, NARCOLEPSY,
PERIPHERAL NEUROPATHY, SLEEP APNEA, CRANIAL NERVE DISORDERS, FIBROMYALGIA,
CHRONIC FATIGUE SYNDROME) 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.
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 consider the information you
provide on this questionnaire as part of their evaluation in processing the veteran’s claim.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE /SHE EVER BEEN DIAGNOSED WITH A CENTRAL NERVOUS SYSTEM (CNS) CONDITION?
YES

NO

(If "Yes," complete Item 1B)

1B. SELECT THE VETERAN’S CONDITION: (check all that apply)

CENTRAL NERVOUS SYSTEM (CNS) INFECTIONS - If checked, provide ICD code:_______________ Date of diagnosis:___________________________
Meningitis
Specify organism:________________________________
Brain abscess
Specify organism:________________________________
HIV
Neurosyphilis
Lyme disease
Encephalitis, epidemic, chronic, including poliomyelitis, anterior (anterior horn cells)
Other (specify):_________________________________________________

VASCULAR DISEASES - If checked, provide ICD code:_______________ Date of diagnosis:__________________________
Thrombosis, TIA or cerebral infarction
Hemorrhage (specify type):_______________________________________
Cerebral arteriosclerosis
Other (specify):________________________________________________

HYDROCEPHALUS - If checked, provide ICD code:_________________ Date of diagnosis:____________________________
Obstructive
Communicating
Normal pressure (NPH)

BRAIN TUMOR - If checked, provide ICD code:_________________ Date of diagnosis: ______________________

SPINAL CORD CONDITIONS - If checked, provide ICD code:_________________ Date of diagnosis:______________________
Syringomyelia
Myelitis
Hematomyelia
Spinal Cord Injuries
Radiation injury
Electric or lightning injury
Decompression sickness (DCS)
Other
Spinal cord tumor
Other (specify):________________________________________________
BRAIN STEM CONDITIONS - If checked, provide ICD code:______________________________ Date of diagnosis:______________________
Bulbar palsy
Pseudobulbar palsy
Other (specify):________________________________________________

VA FORM
FEB 2011

21-0960C-5

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SECTION I - DIAGNOSIS (CONTINUED)
1B. SELECT THE VETERAN’S CENTRAL NERVOUS SYSTEM CONDITION (Continued): (Check all that apply)
MOVEMENT DISORDERS - If checked, provide ICD code:____________________ Date of diagnosis:_________________________
Athetosis, acquired
Myoclonus I
Paramyoclonus multiplex (convulsive state, myoclonic type)
Tic, convulsive (Gilles de la Tourette syndrome)
Dystonia (specify type):________________________________________________________________________
Essential tremor
Tardive dyskenesia or other neuroleptic induced syndromes
Other (specify):_________________________________________

NEUROMUSCULAR DISORDERS - If checked, provide ICD code:___________________ Date of diagnosis:______________________
Myasthenia gravis
Myasthenic syndrome
Botulism
Hereditary muscular disorders
Familial periodic paralysis
Myoglobulinuria
Dermatomyositis or polyomiositis
Other (specify):_______________________________________

INTOXICATIONS - If checked, provide ICD code:____________________ Date of diagnosis:_______________________
Heavy metal intoxication
Solvents (specify):____________________________________________________________________________
Insecticides, pesticides, others (specify):__________________________________________________________
Nerve gas agents
Herbicides/defoliants (specify):__________________________________________________________________
Other (specify):_______________________________________

OTHER CENTRAL NERVOUS SYSTEM CONDITION
Other diagnosis # 1 (specify)__________________________________________________
ICD code:_____________________________ Date of diagnosis:____________________________
Other diagnosis # 2 (specify)____________________ _____________________________________
ICD code:_____________________________ Date of diagnosis:____________________________

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO CENTRAL NERVOUS SYSTEM CONDITIONS, LIST USING ABOVE FORMAT:

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SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN’S CENTRAL NERVOUS SYSTEM CONDITIONS (brief summary):

2B. DOES THE VETERAN’S CENTRAL NERVOUS SYSTEM CONDITIONS REQUIRE CONTINUOUS MEDICATIONS FOR CONTROL?
YES
NO (If "Yes," list medications used for central nervous system conditions):

2C. DOES THE VETERAN HAVE AN INFECTIOUS CONDITION?
YES

NO

(If "Yes," is it active?)
Yes
No
(If "No," describe residuals, if any):

2D. DOMINANT HAND
RIGHT

LEFT

AMBIDEXTROUS

SECTION III - CONDITIONS, SIGNS AND SYMPTOMS
3A. DOES THE VETERAN HAVE ANY MUSCLE WEAKNESS IN THE UPPER AND/OR LOWER EXTREMITIES?
YES

NO

(If "Yes," report under strength testing in Section IV Neurologic Exam)
3B. DOES THE VETERAN HAVE ANY PHARYNX AND/OR LARYNX AND/OR SWALLOWING CONDITIONS?
YES

NO

(If "Yes," check all that apply)
Constant inability to communicate by speech
Speech not intelligible or individual is aphonic
Paralysis of soft palate with swallowing difficulty (nasal regurgitation) and speech impairment
Hoarseness
Mild swallowing difficulties
Moderate swallowing difficulties
Severe swallowing difficulties, permitting passage of liquids only
Requires feeding tube due to swallowing difficulties
Other, (describe):_____________________

3C. DOES THE VETERAN HAVE ANY RESPIRATORY CONDITIONS (such as rigidity of the diaphragm, chest wall or laryngeal muscles)?
YES

NO (If "Yes," provide PFT results under Section XI, "Diagnostic testing")

3D. DOES THE VETERAN HAVE SLEEP DISTURBANCES?
YES

NO (If "Yes," check all that apply)
Insomnia
Hypersomnolence and/or daytime "sleep attacks"
Persistent daytime hypersomnolence
Sleep apnea requiring the use of breathing assistance device such as continuous airway pressure (CPAP) machine
Sleep apnea causing chronic respiratory failure with carbon dioxide retention or cor pulmonale
Sleep apnea requiring tracheostomy

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SECTION III - CONDITIONS, SIGNS AND SYMPTOMS (Continued)
3E. DOES THE VETERAN HAVE ANY BOWEL FUNCTIONAL IMPAIRMENT?
YES
NO
(If "Yes," check all that apply)
Slight impairment of sphincter control, without leakage
Constant slight impairment of sphincter control, or occasional moderate leakage
Occasional involuntary bowel movements, necessitating wearing a pad
Extensive leakage and fairly frequent involuntary bowel movements
Total loss of bowel sphincter control
Chronic constipation
Other bowel impairment (describe):__________________________________________________________________
3F. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING URINE LEAKAGE?
YES
NO
(If "Yes," check all that apply)
Does not require/does not use absorbent material
Requires absorbent material that is changed less than 2 times per day
Requires absorbent material that is changed 2 to 4 times per day
Requires absorbent material that is changed more than 4 times per day
3G. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING SIGNS AND/OR SYMPTOMS OF URINARY FREQUENCY?
YES

NO

(If "Yes," check all that apply)
Daytime voiding interval between 2 and 3 hours
Daytime voiding interval between 1 and 2 hours
Daytime voiding interval less than 1 hour
Nighttime awakening to void 2 times
Nighttime awakening to void 3 to 4 times
Nighttime awakening to void 5 or more times
3H. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING FINDINGS, SIGNS AND/OR SYMPTOMS OF OBSTRUCTED VOIDING?
YES

NO

(If "Yes," check all signs and symptoms that apply)
Hesitancy
(If checked, is hesitancy marked?)
Yes
No
Slow or weak stream
(If checked, is stream markedly slow or weak?)
Yes

No

Decreased force of stream
(If checked, is force of stream markedly decreased?)
Yes
No
Stricture disease requiring dilatation 1 to 2 times per year
Stricture disease requiring periodic dilatation every 2 to 3 months
Recurrent urinary tract infections secondary to obstruction
Uroflowmetry peak flow rate less than 10 cc/sec
Post void residuals greater than 150 cc
Urinary retention requiring intermittent or continuous catheterization
3I. DOES THE VETERAN HAVE VOIDING DYSFUNCTION REQUIRING THE USE OF AN APPLIANCE?
YES

NO (If "Yes," describe):

3J. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT INFECTIONS?
YES
NO
(If "Yes," check all treatments that apply)
No treatment
Long-term drug therapy
(If "Yes," list medications used for urinary tract infection and indicate dates for courses of treatment over the past 12 months):
Hospitalization
(If checked, indicate frequency of hospitalization):
1 or 2 per year
More than 2 per year
Drainage
(If checked, indicate dates when drainage performed over past 12 months):
Dther management/treatment not listed above (Provide a description of management/treatment including dates of treatment):
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SECTION III - CONDITIONS, SIGNS, AND SYMPTOMS (Continued)
3K. DOES THE VETERAN (if male) HAVE ERECTILE DYSFUNCTION?
YES
NO
(If "Yes," is the erectile dysfunction as likely as not (at least 50% probability) attributable to a CNS disease (including treatment or residuals of treatment?)
Yes

No

(If "No," provide the etiology of the erectile
dysfunction):_________________________________________________________________________________________
(If "Yes," is the veteran able to achieve an erection (without medication) sufficient for penetration and ejaculation?)
Yes

No

(If "No," is the veteran able to achieve an erection (with medication) sufficient for penetration and ejaculation?)
Yes

No

SECTION IV - NEUROLOGIC EXAM
4A. SPEECH
Normal

Abnormal

If speech is abnormal, describe:__________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________

4B. GAIT
Normal

Abnormal

If gait is abnormal and the veteran has more than one medical condition contributing to the abnormal gait, identify the conditions and describe each condition’s contribution to
the abnormal gait:_____________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________

4C. STRENGTH - Rate strength according to the following scale:
0/5 No muscle movement
1/5 Visible muscle movement, but no joint movement
2/5 No movement against gravity
3/5 No movement against resistance
4/5 Less than normal strength
5/5 Normal strength
ALL NORMAL
Elbow flexion:

Elbow extension:

Wrist flexion:

Wrist extension:

Grip:

Pinch (thumb to
index finger):
Knee extension:
Ankle plantar
flexion:
Ankle dorsiflexion:

VA FORM 21-0960C-5, FEB 2011

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

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SECTION IV - NEUROLOGIC EXAM (Continued)
4D. DEEP TENDON REFLEXES (DTRs) - Rate reflexes according to the following scale:
0 Absent
1+ Decreased
2+ Normal
3+ Increased without clonus
4+ Increased with clonus
ALL NORMAL
Biceps:

Triceps:

Brachioradialis:

Knee:

Ankle:

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

4E. DOES THE VETERAN HAVE MUSCLE ATROPHY ATTRIBUTABLE TO A CNS CONDITION?
YES

NO

(If muscle atrophy is present, indicate location):_____________________________________________________________________________________________
(When possible, provide difference measured in cm between normal and atrophied side, measured at maximum muscle bulk):________ cm
4F. SUMMARY OF MUSCLE WEAKNESS IN THE UPPER AND/OR LOWER EXTREMITIES ATTRIBUTABLE TO A CNS CONDITION (check all that apply):
Right upper extremity muscle weakness:
None

Mild

Moderate

Severe

With atrophy

Complete (no remaining function)

Severe

With atrophy

Complete (no remaining function)

Severe

With atrophy

Complete (no remaining function)

Severe

With atrophy

Complete (no remaining function)

Left upper extremity muscle weakness:
None

Mild

Moderate

Right lower extremity muscle weakness:
None

Mild

Moderate

Left lower extremity muscle weakness:
None

Mild

Moderate

4G. IFTHE VETERAN HAVE MORE THAN ONE MEDICAL CONDITION CONTRIBUTING TO THE MUSCLE WEAKNESS, IDENTIFY THE CONDITION(S) AND DESCRIBE
EACH CONDITION’S CONTRIBUTION TO THE MUSCLE WEAKNESS:

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SECTION V - TUMORS AND NEOPLASMS
5A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I ?
YES
NO
(If "Yes," complete Items 5B through 5E)
5B. IS THE NEOPLASM?
BENIGN

MALIGNANT

5C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT
NEOPLASM OR METASTASES?
YES

NO; WATCHFUL WAITING

(If "Yes," indicate type of treatment the veteran is currently undergoing or has completed (check all that apply)
Treatment completed; currently in watchful waiting status
Surgery - Describe:_______________________________________________________________________ date(s) of surgery:_________________________
Radiation therapy - Provide date of most recent treatment:____________ date of completion of treatment or anticipated date of completion:__________
Antineoplastic chemotherapy - Provide date of most recent treatment:___________ date of completion of treatment or anticipated date of completion:__________
Other therapeutic procedure - Describe procedure:__________________________________________________ date of most recent procedure:_____________
Other therapeutic treatment - Describe treatment: ___________________________ date of completion of treatment or anticipated date of completion:__________
5D. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM (including metastases) OR ITS TREATMENT,
OTHER THAN THOSE ALREADY DOCUMENTED IN THE REPORT ABOVE?
NO
YES
(If "Yes," list residual conditions and complications (brief summary)):

5E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DESCRIBE:

SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
6A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I ?
YES

NO

(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches))?
Yes

No

(If "Yes," also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
6B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I ?
YES

NO

(If "Yes," describe (brief summary)):

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SECTION VII - MENTAL HEALTH MANIFIESTATIONS DUE TO CNS CONDITION OR ITS TREATMENT
7A. DOES THE VETERAN HAVE ANY DEPRESSION, COGNITIVE IMPAIRMENT OR DEMENTIA, OR ANY OTHER MENTAL HEALTH CONDITIONS ATTRIBUTABLE TO A
CNS DISEASE AND/OR ITS TREATMENT?
YES
NO
7B. DOES THE VETERAN’S MENTAL HEALTH CONDITION(S), AS IDENTIFIED IN ITEM 7A, RESULT IN GROSS IMPAIRMENT IN THOUGHT PROCESSES OR
COMMUNICATION?
YES

NO

(If "No," also complete the VA Form 21-0960P-2, Mental Disorders Disability Benefits Questionnaire)
(If "Yes," briefly describe the veteran’s mental health condition):________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

SECTION VIII - DIFFERENTIATION OF SYMPTOMS OR NEUROLOGIC EFFECTS
8. ARE YOU ABLE TO DIFFERENTIATE WHAT PORTION OF THE SYMPTOMOTOLOGY OR NEUROLOGIC EFFECTS IN SECTION III IS CAUSED BY EACH
YES

NO

(If "Yes," list which symptoms or neurologic effects are attributable to each diagnosis, where possible):__________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________

SECTION IX - ASSISTIVE DEVICES
9A. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES

NO

(If "Yes," identify assistive device(s) used (check all that apply and indicate frequency)):
Wheelchair

Frequency of use:

Occasional

Regular

Constant

Brace(s)

Frequency of use:

Occasional

Regular

Constant

Crutch(es)

Frequency of use:

Occasional

Regular

Constant

Cane(s)

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other:____________ Frequency of use:
Constant
Regular
Occasional
_________________
_________________
_________________
9B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

SECTION X - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
10. DUE TO A CNS CONDITION, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS OTHER THAN THAT
WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS? (Functions of the upper extremity include grasping, manipulation, etc.,
while functions for the lower extremity include balance and propulsion, etc.)
YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS WOULD EQUALLY SERVE THE VETERAN
NO
(If "Yes," indicate extremity(ies) (check all extremities for which this applies)):
Right upper

Left upper

Right lower

Left lower

(For each checked extremity, describe loss of effective function, identify the condition causing loss of function, and provide specific examples (brief summary):

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SECTION XI - DIAGNOSTIC TESTING
NOTE - If the results of MRI, other imaging studies or other diagnostic tests are in the medical record and reflect the veterans’s current condition, repeat
testing is not required. If pulmonary function testing (PFT) is indicated due to respiratory disability, and results are in the medical record and reflect the
veteran’s current respiratory function, repeat testing is not required. DLCO and bronchodilator testing is not indicated for a restrictive respiratory
disability such as that caused by muscle weakness due to CNS conditions.
11A. HAVE IMAGING STUDIES BEEN PERFORMED?
YES

NO

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

11B. HAVE PFTs BEEN PERFORMED?
YES
NO
(If "Yes," provide most recent results, if available):
FEV-1:________________ % predicted Date of test:______________________
FEV-1/FVC:____________ % predicted Date of test:______________________
FVC:_________________ % predicted Date of test:______________________
11C. IF PFTs HAVE BEEN PERFORMED, IS THE FLOW-VOLUME LOOP COMPATIBLE WITH UPPER AIRWAY OBSTRUCTION?
YES

NO

11D. 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 XII - FUNCTIONAL IMPACT AND REMARKS
12. DO THE VETERAN’S CENTRAL NERVOUS SYSTEM DISORDERS IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
(If "Yes," describe impact of each of the veteran’s central nervous system disorder condition(s), providing one or more examples):

13. REMARKS (If any)

SECTION XIII - PHYSICIAN’S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
14A. PHYSICIAN’S SIGNATURE

14D. PHYSICIAN’S PHONE NUMBER

14B. PHYSICIAN’S PRINTED NAME

14E. PHYSICIAN’S MEDICAL LICENSE NUMBER

14C. DATE SIGNED

14F. PHYSICIAN’S ADDRESS

NOTE - VA may request additional medical information, including additional examinations 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, 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 low 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 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.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 21-0960C-5, FEB 2011

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