VA Form 21-0960F-1 Scars/Disfigurement Disability Benefits Questionnaire

OMB Approved No. 2900-0776
Respondent Burden: 15 minutes

SCARS/DISFIGUREMENT 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 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 HAVE ONE OR MORE SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK?
YES

NO

(If "Yes," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK:
DIAGNOSIS # 1:

ICD CODE:

DATE OF DIAGNOSIS:

DIAGNOSIS # 2:

ICD CODE:

DATE OF DIAGNOSIS:

DIAGNOSIS # 3:

ICD CODE:

DATE OF DIAGNOSIS:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK DUE
TO SCARS OR OTHER CAUSES, LIST USING ABOVE FORMAT:

INSTRUCTIONS: Provide all linear measurements in centimeters and area measurements in centimeters squared.
For non-linear scars, measure the length and width at their widest points.
After measuring the scars, use the summary sections to provide the combined approximate total area for all scars in each region.
If scars are too numerous to count (for example, multiple scattered shrapnel wound scars, acne scarring or pseudofolliculitis barbae), indicate “TNTC”
and provide approximate combined total area.
NOTE: For VA purposes, superficial non-linear scars are those not associated with underlying soft tissue damage, while deep non-linear scars are
associated with underlying soft tissue damage.
SECTION II - SCARS OF THE TRUNK AND EXTREMITIES
DOES THE VETERAN HAVE ANY SCARS ON THE TRUNK OR EXTREMITIES (REGIONS OTHER THAN THE HEAD, FACE OR NECK)?
YES

NO (If "Yes," complete this section)

(If "No," skip to Section III)

1. MEDICAL HISTORY
A. DESCRIBE THE HISTORY (including cause/origin and course) OF THE VETERAN'S SCAR(S) OF THE TRUNK OR EXTREMITIES (Brief summary):

B. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES PAINFUL?
YES

NO

If yes, specify the number of painful scars:

1

2

3

4

5 or more

Describe the pain (if there are multiple painful scars, be sure to adequately identify which scars are painful):

C. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES UNSTABLE, WITH FREQUENT LOSS OF COVERING OF SKIN OVER THE SCAR?
YES

NO

If yes, specify the number of unstable scars:

1

2

3

4

5 or more

Describe the loss of covering of skin over the scar (if there are multiple unstable scars, be sure to adequately identify which scars are unstable):

D. ARE ANY OF THE SCARS BOTH PAINFUL AND UNSTABLE?
YES

NO

If yes, specify number of scars that are both painful and unstable:

1

2

3

4

5 or more

Describe the location of these scars:

VA FORM
JAN 2011

21-0960F-1

Page 1

SECTION II - SCARS OF THE TRUNK AND EXTREMITIES (continued)
E. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES DUE TO BURNS?
YES

If yes, identify each burn scar and state depth of original burn:

NO

Burn scar #1:
Full thickness or sub-dermal
Deep partial thickness
Less than deep partial thickness
Burn scar #2:
Full thickness or sub-dermal
Deep partial thickness
Less than deep partial thickness
If there are additional burn scars of the trunk and extremities, list using the same format:

2. PHYSICAL EXAM FOR SCARS ON THE TRUNK AND EXTREMITIES
2.1 Details of scar findings for the trunk and extremities
INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:
A. RIGHT UPPER EXTREMITY
Affected

Not affected

Specify location of scars on right upper extremity and number them:
Indicate types of scars and provide measurements (check all that apply)
Linear
Length of each linear scar:
Scar # 1:

cm

Scar # 2:

cm

Scar # 3:

Scar # 4:

cm

Scar # 5:

cm

If additional scars, list using same format:

cm

Superficial non-linear
Length and width of each superficial non-linear scar:
Scar # 1:

x

cm

Scar # 2:

x

cm

Scar # 3:

Scar # 4:

x

cm

Scar # 5:

x

cm

If additional scars, list using same format:

x

cm

Deep non-linear
Length and width of each deep non-linear scar:
Scar # 1:

x

cm

Scar # 2:

x

cm

Scar # 3:

Scar # 4:

x

cm

Scar # 5:

x

cm

If additional scars, list using same format:

x

cm

B. LEFT UPPER EXTREMITY
Affected

Not affected

Specify location of scars on left upper extremity and number them:
Indicate types of scars and provide measurements (check all that apply)
Linear
Length of each linear scar:
Scar # 1:

cm

Scar # 2:

cm

Scar # 3:

Scar # 4:

cm

Scar # 5:

cm

If additional scars, list using same format:

cm

Superficial non-linear
Length and width of each superficial non-linear scar:
Scar # 1:

x

cm

Scar # 2:

x

cm

Scar # 3:

Scar # 4:

x

cm

Scar # 5:

x

cm

If additional scars, list using same format:

x

cm

Deep non-linear
Length and width of each deep non-linear scar:
Scar # 1:

x

cm

Scar # 2:

x

cm

Scar # 3:

Scar # 4:

x

cm

Scar # 5:

x

cm

If additional scars, list using same format:

x

cm

C. RIGHT LOWER EXTREMITY
Affected

Not affected

Specify location of scars on right lower extremity and number them:
Indicate types of scars and provide measurements (check all that apply)
Linear
Length of each linear scar:
Scar # 1:

cm

Scar # 2:

cm

Scar # 3:

Scar # 4:

cm

Scar # 5:

cm

If additional scars, list using same format:

VA FORM 21-0960F-1, JAN 2011

cm

Page 2

SECTION II - SCARS OF THE TRUNK AND EXTREMITIES (continued)
2.1 Details of scar findings for the trunk and extremities (continued)
INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:
Superficial non-linear
Length and width of each superficial non-linear scar:
Scar # 1:

x

cm

Scar # 2:

x

cm

Scar # 3:

Scar # 4:

x

cm

Scar # 5:

x

cm

If additional scars, list using same format:

x

cm

Deep non-linear
Length and width of each deep non-linear scar:
Scar # 1:

x

cm

Scar # 2:

x

cm

Scar # 3:

Scar # 4:

x

cm

Scar # 5:

x

cm

If additional scars, list using same format:

x

cm

D. LEFT LOWER EXTREMITY
Affected

Not affected

Specify location of scars on left lower extremity and number them:
Indicate types of scars and provide measurements (check all that apply)
Linear
Length of each linear scar:
Scar # 1:

cm

Scar # 2:

cm

Scar # 3:

Scar # 4:

cm

Scar # 5:

cm

If additional scars, list using same format:

cm

Superficial non-linear
Length and width of each superficial non-linear scar:
Scar # 1:

x

cm

Scar # 2:

x

cm

Scar # 3:

Scar # 4:

x

cm

Scar # 5:

x

cm

If additional scars, list using same format:

x

cm

Deep non-linear
Length and width of each deep non-linear scar:
Scar # 1:

x

cm

Scar # 2:

x

cm

Scar # 3:

Scar # 4:

x

cm

Scar # 5:

x

cm

If additional scars, list using same format:

x

cm

E. ANTERIOR TRUNK
Affected

Not affected

Specify location of scars on anterior trunk and number them:
Indicate types of scars and provide measurements (check all that apply)
Linear
Length of each linear scar:
Scar # 1:

cm

Scar # 2:

cm

Scar # 3:

Scar # 4:

cm

Scar # 5:

cm

If additional scars, list using same format:

cm

Superficial non-linear
Length and width of each superficial non-linear scar:
Scar # 1:

x

cm

Scar # 2:

x

cm

Scar # 3:

Scar # 4:

x

cm

Scar # 5:

x

cm

If additional scars, list using same format:

x

cm

Deep non-linear
Length and width of each deep non-linear scar:
Scar # 1:

x

cm

Scar # 2:

x

cm

Scar # 3:

Scar # 4:

x

cm

Scar # 5:

x

cm

If additional scars, list using same format:

x

cm

F. POSTERIOR TRUNK
Affected

Not affected

Specify location of scars on posterior trunk and number them:
Indicate types of scars and provide measurements (check all that apply)
Linear
Length of each linear scar:
Scar # 1:

cm

Scar # 2:

cm

Scar # 3:

Scar # 4:

cm

Scar # 5:

cm

If additional scars, list using same format:

cm

Superficial non-linear
Length and width of each superficial non-linear scar:
Scar # 1:

x

cm

Scar # 2:

x

cm

Scar # 3:

Scar # 4:

x

cm

Scar # 5:

x

cm

If additional scars, list using same format:

VA FORM 21-0960F-1, JAN 2011

x

cm

Page 3

SECTION II - SCARS OF THE TRUNK AND EXTREMITIES (continued)
2.1 Details of scar findings for the trunk and extremities (continued)

INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:
Deep non-linear
Length and width of each deep non-linear scar:
Scar # 1:

x

cm

Scar # 2:

x

cm

Scar # 3:

Scar # 4:

x

cm

Scar # 5:

x

cm

If additional scars, list using same format:

x

cm

2.2 Details of scar findings for the trunk and extremities (continued)
A. SUPERFICIAL NON-LINEAR SCARS (CHECK ALL THAT APPLY AND PROVIDE APPROXIMATE COMBINED TOTAL AREA IN CENTIMETERS SQUARED FOR EACH
AFFECTED ANATOMICAL REGION)
None
Right upper extremity:

Approximate total area:

cm2

Left upper extremity:

Approximate total area:

cm2

Right lower extremity:

Approximate total area:

cm2

Left lower extremity:

Approximate total area:

cm2

Anterior trunk:

Approximate total area:

cm2

Posterior trunk:

Approximate total area:

cm2

B. DEEP NON-LINEAR SCARS (CHECK ALL THAT APPLY AND PROVIDE APPROXIMATE COMBINED TOTAL AREA IN CENTIMETERS SQUARED FOR EACH
AFFECTED ANATOMICAL REGION)
None
Right upper extremity:

Approximate total area:

cm2

Left upper extremity:

Approximate total area:

cm2

Right lower extremity:

Approximate total area:

cm2

Left lower extremity:

Approximate total area:

cm2

Anterior trunk:

Approximate total area:

cm2

Posterior trunk:

Approximate total area:

cm2

SECTION III: SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK
DOES THE VETERAN HAVE ANY SCARS OR DISFIGUREMENT OF HEAD, FACE OR NECK?
YES

NO

(If "Yes," complete this section) (If "No," skip to Section IV)

1. MEDICAL HISTORY
A. DESCRIBE THE HISTORY (including cause/origin and course) OF THE VETERAN'S SCAR(S) OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK (Brief
summary):

B. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK PAINFUL?
3
4
If yes, specify the number of painful scars:
1
2
5 or more
YES
NO
Describe the pain (if there are multiple painful scars, be sure to adequately identify which scars are painful):

C. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK UNSTABLE, WITH FREQUENT LOSS OF COVERING OF SKIN OVER THE SCAR?
YES

NO

If yes, specify the number of unstable scars:

1

2

3

4

5 or more

Describe the loss of covering of skin over the scar (if there are multiple unstable scars, be sure to adequately identify which scars are unstable):

D. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK BOTH PAINFUL AND UNSTABLE?
YES

NO

If yes, specify number of scars that are both painful and unstable:

1

2

3

4

5 or more

Describe the location of these scars:

E. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK DUE TO BURNS?
YES

NO

If yes, identify each burn scar and state depth of original burn:

Burn scar #1:
Full thickness or sub-dermal
Deep partial thickness
Burn scar #2:

Less than deep partial thickness
Full thickness or sub-dermal
Deep partial thickness
Less than deep partial thickness

VA FORM 21-0960F-1, JAN 2011

Page 4

SECTION III - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK (continued)
1. MEDICAL HISTORY (continued)
If there are additional burn scars of the head, face or neck, list using the same format:

2. PHYSICAL EXAM FOR SCARS OR DISFIGUREMENT OF THE HEAD, FACE AND NECK
2.1 Details of scar or disfigurement for the head, face and neck
A. IDENTIFY EACH SCAR OR DISFIGUREMENT AND PROVIDE MEASUREMENTS:
Scar/Disfigurement #1
Indicate type of impairment:

Scar

Disfigurement

Location of scar/disfigurement #1
Length and width (at widest part) of scar/disfigurement #1:

x

cm

x

cm

x

cm

x

cm

x

cm

Scar/Disfigurement #2
Indicate type of impairment:

Scar

Disfigurement

Location of scar/disfigurement #2
Length and width (at widest part) of scar/disfigurement #2:
Scar/Disfigurement #3
Indicate type of impairment:

Scar

Disfigurement

Location of scar/disfigurement #3
Length and width (at widest part) of scar/disfigurement #3:
Scar/Disfigurement #4
Indicate type of impairment:

Scar

Disfigurement

Location of scar/disfigurement #4
Length and width (at widest part) of scar/disfigurement #4:
Scar/Disfigurement #5
Indicate type of impairment:

Scar

Disfigurement

Location of scar/disfigurement #5
Length and width (at widest part) of scar/disfigurement #5:
If additional scars or disfigurement, list using the same format:
B. IS THERE ELEVATION, DEPRESSION, ADHERENCE TO UNDERLYING TISSUE, OR MISSING UNDERLYING SOFT TISSUE?
YES

NO

If, yes check all that apply
Surface contour elevated on palpation
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1

Scar/Disfigurement #2

Scar/Disfigurement #3

Scar/Disfigurement #4

Scar/Disfigurement #5

Other

Surface contour depressed on palpation
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1

Scar/Disfigurement #2

Scar/Disfigurement #3

Scar/Disfigurement #4

Scar/Disfigurement #5

Other

Scar adherent to underlying tissue
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1

Scar/Disfigurement #2

Scar/Disfigurement #3

Scar/Disfigurement #4

Scar/Disfigurement #5

Other

Underlying soft tissue missing
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1

Scar/Disfigurement #2

Scar/Disfigurement #3

Scar/Disfigurement #4

Scar/Disfigurement #5

Other

VA FORM 21-0960F-1, JAN 2011

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SECTION III - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK (continued)
2.1 Details of scar or disfigurement for the head, face and neck
C. IS THERE ABNORMAL PIGMENTATION OR TEXTURE OF THE HEAD, FACE, OR NECK?
YES

NO

If, yes check all that apply
Hypopigmentation
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1

Scar/Disfigurement #2

Scar/Disfigurement #3

Scar/Disfigurement #4

Scar/Disfigurement #5

Other

Hyperpigmentation
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1

Scar/Disfigurement #2

Scar/Disfigurement #3

Scar/Disfigurement #4

Scar/Disfigurement #5

Other

Induration and inflexibility
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1

Scar/Disfigurement #2

Scar/Disfigurement #3

Scar/Disfigurement #4

Scar/Disfigurement #5

Other

Abnormal texture
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1

Scar/Disfigurement #2

Scar/Disfigurement #3

Scar/Disfigurement #4

Scar/Disfigurement #5

Other

Describe type of abnormal texture (for example, irregular, atrophic, shiny or scaly):

2.2 Summary of scars or other disfigurement of the head, face and neck
Provide approximate combined total area in centimeters squared for each characteristic of disfigurement:
a. Approximate total area of head, face and neck with hypo- or hyperpigmented areas:

cm2

b. Approximate total area of head, face and neck with abnormal texture:

cm2

c. Approximate total area of head, face and neck with missing underlying soft tissue:

cm2

d. Approximate total area of head, face and neck that is indurated and inflexible:

cm2

2.3 Distortion of facial features and tissue loss for the head, face and neck
Is there gross distortion or asymmetry of facial features or visible or palpable tissue loss?
YES

NO

If yes, indicate features affected (check all that apply):
Nose

Chin

Forehead

Cheeks

Lips

Eyes (including eyelids) (If checked, specify):
Tissue loss/distortion of eyelid

Side:

Right

Tissue loss/distortion of eye

Side:

Right

Left
Left

Anatomical loss of eye

Side:

Right

Left

Complete loss of auricle

Side:

Right

Left

Deformity of auricle, with loss of
less than one-third the substance
Deformity of auricle, with loss of
one-third or more of the substance

Side:

Right

Left

Side:

Right

Left

Ears (auricles) (If checked, specify):

For all checked features, provide brief description of the tissue loss, gross distortion and/or asymmetry of facial features:

VA FORM 21-0960F-1, JAN 2011

Page 6

SECTION IV - MISCELLANEOUS
NOTE: Complete this section for all scars or disfigurements, regardless of location.

1. LIMITATION OF FUNCTION/OTHER CONDITIONS
A. Do any of the scars (regardless of location) or disfigurement of the head, face or neck result in limitation of function?
YES

NO

If yes, indicate which scars (regardless of location) or disfigurement of the head, face, or neck are causing the limitation and describe the specific limitations:

B. Does the veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms (such as muscle or nerve damage) associated with any
scar (regardless of location) or disfigurement of the head, face, or neck?
YES

NO

If yes, describe (brief summary):

2. COLOR PHOTOGRAPHS
Provide color photographs, if possible, for any disfiguring conditions of the head, face and/or neck.
Photographs not indicated

Photographs provided

Photographs not available

SECTION V - FUNCTIONAL IMPACT
Does the veteran's scar(s) (regardless of location) or disfigurement of the head, face, or neck impact his or her ability to work?
YES

NO

If yes, describe impact of the veteran's scar(s) (regardless of location) or disfigurement of the head, face, or neck, providing one or more examples:

SECTION VI - REMARKS
Remarks (If any)

SECTION VII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
Physician signature:

Physician printed name:

Physician's Phone and Fax Number:

Physician's Medical license Number:

Date:

Physician 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 21-0960F-1, JAN 2011

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