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pdfOMB Approved No. 2900-0776
Respondent Burden: 45 minutes
EYE CONDITIONS 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. This report is not for treatment purposes; it is to provide a summary of medical
information for disability claims resolution.
NOTE: This examination must be conducted by a licensed ophthalmologist or by a licensed optometrist. The examiner must identify the disease, injury or other
pathologic process responsible for any decrease in visual acuity or other visual impairment found. Examinations of visual fields or muscle function should be conducted
ONLY when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function. Unless medically
contraindicated, the fundus must be examined with the Veteran's pupils dilated.
SECTION I: DIAGNOSIS
NOTE: The diagnosis section should be filled out AFTER the clinician has completed the examination.
1. Does the Veteran now have or has he/she ever been diagnosed with an eye condition (other than congenital or developmental errors of refraction)?
If "Yes," provide only diagnoses that pertain to eye conditions:
Diagnosis #1:
ICD code(s):
Date of diagnosis:
Diagnosis #2:
ICD code(s):
Date of diagnosis:
Diagnosis #3:
ICD code(s):
Date of diagnosis:
Yes
No
If there are additional diagnoses that pertain to eye conditions, list using above format:
SECTION II: MEDICAL HISTORY
2. Describe the history (including onset and course) of the Veteran's current eye condition(s) (Brief summary):
SECTION III: PHYSICAL EXAMINATION
1. VISUAL ACUITY
Visual acuity should be reported according to the lines on the Snellen chart or its equivalent. If assessment of the Veteran's visual acuity falls between two lines on the
Snellen chart, round up to the higher (worse) level (poorer vision) for answers a-d below. (For example, 20/60 would be reported as 20/70; 20/80 would be reported as
20/100, etc.)
Examination of visual acuity must include central uncorrected and corrected visual acuity for distance and near vision. Evaluate visual acuity on the basis of corrected
distance vision with central fixation. Visual acuity should not be determined with eccentric fixation or viewing.
a. Uncorrected distance:
Right:
5/200
10/200
15/200
20/200
20/100
20/70
20/50
20/40 or better
5/200
10/200
15/200
20/200
20/100
20/70
20/50
20/40 or better
b. Uncorrected near:
5/200
Right:
10/200
15/200
20/200
20/100
20/70
20/50
20/40 or better
5/200
10/200
15/200
20/200
20/100
20/70
20/50
20/40 or better
Left:
Left:
c. Corrected distance:
Right:
5/200
10/200
15/200
20/200
20/100
20/70
20/50
20/40 or better
Left:
5/200
10/200
15/200
20/200
20/100
20/70
20/50
20/40 or better
d. Corrected near:
5/200
Right:
10/200
15/200
20/200
20/100
20/70
20/50
20/40 or better
5/200
10/200
15/200
20/200
20/100
20/70
20/50
20/40 or better
Left:
VA FORM
JAN 2011
21-0960N-2
Page 1
SECTION III: PHYSICAL EXAMINATION (Continued)
2. DIFFERENCE IN CORRECTED VISUAL ACUITY FOR DISTANCE AND NEAR VISION
Does the Veteran have a difference equal to two or more lines on the Snellen test type chart or its equivalent between distance and near corrected vision, with the near vision
being worse?
Yes
No
(If "Yes," complete Items 2A thru 2C)
a. Provide a second recording of corrected distance and near vision
Second recording of corrected distance vision
5/200
10/200
Right:
15/200
20/200
20/100
20/70
20/50
20/40 or better
15/200
20/200
20/100
20/70
20/50
20/40 or better
Second recording of corrected near vision
5/200
10/200
Right:
15/200
20/200
20/100
20/70
20/50
20/40 or better
20/200
20/100
20/70
20/50
20/40 or better
Left:
Left:
5/200
10/200
5/200
10/200
15/200
b. Explain reason for the difference between distance and near corrected vision
c. Does the lens required to correct distance vision in the poorer eye differ by more than 3 diopters from the lens required to correct distance vision in the better eye?
Yes
No
(If "Yes," explain reason for the difference)
3. PUPILS
a. Pupil diameter: Right:
mm
Left:
mm
b. Pupils are round and reactive to light
Yes
No
c. Is an afferent papillary defect present?
Yes
No
Left
Both
(If "Yes," indicate eye(s))
Right
d. Other, describe:
Eyes affected:
Right
Left
Both
4. ANATOMICAL LOSS, LIGHT PERCEPTION ONLY, EXTREMELY POOR VISION OR BLINDNESS
Does the Veteran have anatomical loss, light perception only, extremely poor vision or blindness of either eye?
Yes
No
(If "Yes," complete Items 4A thru 4E)
a. Does the Veteran have anatomical loss of either eye?
If "Yes," indicate for which eye
Right
Yes
Left
If "Yes," is Veteran able to wear an ocular prosthesis
No
Both
Yes
No
If "No," provide reason
b. Is the Veteran's vision limited to no more than light perception only in either eye?
Yes
No
If "Yes," indicate for which eye(s) the Veteran's vision is limited to no more than light perception
c. Is the Veteran able to recognize test letters at 1 foot or closer?
Yes
Right
Left
Both
No
If "No," indicate with which eye(s) the Veteran is unable to recognize test letters at 1 foot or closer
d. Is the Veteran able to perceive objects, hand movements, or count fingers at 3 feet?
Yes
Right
Left
Both
No
If "No," indicate with which eye(s) the Veteran is unable to perceive objects, hand movements, or count fingers at 3 feet:
Right
Left
Both
e. Does the Veteran have visual acuity of 20/200 or less in the better eye with use of a correcting lens based upon visual acuity loss (i.e. USA statutory blindness with
bilateral visual acuity of 20/200 or less)?
Yes
No
5. ASTIGMATISM
Does the Veteran have a corneal irregularity that results in severe irregular astigmatism?
Yes
No
(If "Yes," complete Items 5A and 5B)
a. Does the Veteran customarily wear contact lenses to correct for the above corneal irregularity?
Yes
No
If "Yes," does using contact lenses result in more visual improvement than using the standard spectacle correction?
b. Was the corrected visual acuity determined using contact lenses?
Yes
Yes
No
No
(If "No," explain
VA FORM 21-0960N-2, JAN 2011
Page 2
SECTION III: PHYSICAL EXAMINATION (Continued)
6. DIPLOPIA
Does the veteran have diplopia (double vision)?
Yes
(If "Yes," complete Items 6A thru 6D)
No
a. Provide etiology (such as traumatic injury, thyroid eye disease, myasthenia gravis, etc.):
b. The areas of diplopia must be documented on a Goldman perimeter chart that identifies the four major quadrants (upward, downward, left lateral and right lateral) and the
central field (20 degrees or less). Include the chart with this questionnaire.
Report the results from the Goldman perimeter chart below.
Indicate the areas where diplopia is present (the fields in which the veteran sees double using binocular vision)
Central 20 degrees
21 to 30 degrees
c. Indicate frequency of the diplopia:
31 to 40 degrees
Greater than 40 degrees
Down
Down
Down
Lateral
Lateral
Lateral
Up
Up
Up
Constant
Occasional
If occasional, indicate frequency of diplopia and most recent occurrence:
d. Is the diplopia correctable with standard spectacle correction?
Yes
No
(If "No," complete Item 6E)
e. Is the diplopia correctable with standard spectacle correction that includes a special prismatic correction?
Yes
No
7. TONOMETRY
a. If tonometry was performed, provide results:
Right eye pressure:
Left eye pressure:
b. Tonometry method used:
Goldmann applanation
Other (Describe) :
8. SLIT LAMP AND EXTERNAL EYE EXAM
a. External exam/lids/lashes:
Right
Normal
Other (Describe) :
Left
Normal
Other (Describe) :
b. Conjunctiva/sclera:
Right
Normal
Other (Describe) :
Left
Normal
Other (Describe) :
c. Cornea:
Right
Normal
Other (Describe) :
Left
Normal
Other (Describe) :
d. Anterior chamber
Right
Normal
Other (Describe) :
Left
Normal
Other (Describe) :
e. Iris:
Right
Normal
Other (Describe) :
Normal
Other (Describe) :
f. Lens:
Right
Normal
Other (Describe) :
Left
Normal
Other (Describe) :
Left
9. INTERNAL EYE EXAM (FUNDUS)
Fundus:
Normal bilaterally
Abnormal
(If Abnormal, complete Items 9A thru 9E)
a. Optic disc:
Right
Normal
Other (Describe) :
Left
Normal
Other (Describe) :
b. Macula:
Right
Normal
Other (Describe) :
Left
Normal
Other (Describe) :
VA FORM 21-0960N-2, JAN 2011
Page 3
SECTION III: PHYSICAL EXAMINATION (Continued)
9. INTERNAL EYE EXAM (Continued)
c. Vessels:
Right
Normal
Other (Describe) :
Left
Normal
Other (Describe) :
Right
Normal
Other (Describe) :
Left
Normal
Other (Describe) :
Right
Normal
Other (Describe) :
Left
Normal
Other (Describe) :
d. Vitreous:
e. Periphery:
10. VISUAL FIELDS
Does the veteran have a visual field defect (or a condition that may result in a visual field defect)?
Yes
No
(If "Yes," complete Items 10A thru 10E)
NOTE: For VA purposes, examiners must perform visual field testing using either Goldmann kinetic perimetry or automated perimetry using Humphrey Model 750,
Octopus Model 101, or later versions of these perimetric devices with simulated kinetic Goldmann testing capability. The results must be recorded on a standard
Goldmann chart providing at least 16 meridians 22½-degrees apart for each eye and included with this questionnaire.
If additional testing is necessary to evaluate visual fields, it must be conducted using either a tangent screen or a 30-degree threshold visual field with the Goldmann III
stimulus size. The examination report must then include the tracing of either the tangent screen or of the 30-degree threshold visual field with the Goldmann III stimulus
size.
a. Was visual field testing performed?
Results:
Yes
No
Using Goldmann's equivalent III/4e target
Using Goldmann's equivalent IV/4e target (used for aphakic individuals not well adapted to contact lens correction or pseudophakic individuals not well
adapted to intraocular lens implant)
Other (Describe) :
b. Does the Veteran have contraction of a visual field?
c. Does the Veteran have loss of a visual field?
Yes
Yes
(If "Yes," include the Goldmann chart with this questionnaire)
No
(If "Yes," check all that apply and indicate eye affected)
No
Homonymous hemianopsia
Right
Left
Both
Loss of temporal half of visual field
Right
Left
Both
Loss of nasal half of visual field
Right
Left
Both
Loss of inferior half of visual field
Right
Left
Both
Loss of superior half of visual field
Right
Left
Both
Other (Specify)
:
d. Does the Veteran have a scotoma?
Yes
No
(If "Yes," check all that apply and indicate eye affected)
Scotoma affecting at least 1/4 of the visual field
Right
Left
Both
Centrally located scotoma
Right
Left
Both
e. Does the Veteran have legal (statutory) blindness (visual field diameter of 20 degrees or less in the better eye, even if the corrected visual acuity is 20/20) based upon visual
field loss?
Yes
No
SECTION IV: EYE CONDITIONS
1. CONDITIONS
Does the veteran have any of the following eye conditions?
Yes
No
(If "No," proceed to Section V.)
(If "Yes," check all that apply)
Anatomical loss of eyelids, brows, lashes (If checked, complete Item 2 below)
Lacrimal gland and lid disorders (other than ptosis or anatomic loss) (If checked, complete Item 3 below)
Ptosis, for either or both eyelids (If checked, complete Item 4 below)
Conjunctivitis and other conjunctival conditions (If checked, complete Item 5 below)
Corneal conditions (If checked, complete Item 6 below)
Cataract and other lens conditions (If checked, complete Item7 below)
Inflammatory eye conditions and/or injuries (If checked, complete Item 8 below)
Glaucoma (If checked, complete Item 9 below)
Optic neuropathy and other disc conditions (If checked, complete Item 10 below)
Retinal conditions (If checked, complete Item 11 below)
Neurologic eye conditions (If checked, complete Item 12 below)
Tumors and neoplasms (If checked, complete Item 13 below)
Other eye conditions (If checked, complete Item 14 below)
For each checked answer, complete the appropriate item (Items 2 thru 14) below:
VA FORM 21-0960N-2, JAN 2011
Page 4
SECTION IV: EYE CONDITIONS (Continued)
2. ANATOMICAL LOSS OF EYELIDS, BROWS,LASHES
a. Indicate condition and side affected (Check all that apply)
Partial or complete loss of eyelid
Side affected:
Right
Left
Both
Complete loss of eyebrows
Side affected:
Right
Left
Both
Complete loss of eyelashes
Side affected:
Right
Left
Both
b. Is the Veteran's decrease in visual acuity or other visual impairment, if present, attributable to eyelid loss?
Yes
There is no decrease in visual acuity or other visual impairment
No
If No," explain
Yes
c. If present, does eyelid loss cause scarring or disfigurement?
(If "Yes," complete Section V, Scarring and Disfigurement)
No
3. LACRIMAL GLAND AND LID CONDITIONS
a. Indicate the Veteran's condition(s) and side affected (Check all that apply):
Ectropion
Side affected:
Right
Left
Both
Entropion
Side affected:
Right
Left
Both
Lagophthalmos
Side affected:
Right
Left
Both
Disorders of the lacrimal apparatus (epiphora, dacryocystitis, etc.)
If checked, specify condition:
Side affected:
Right
Left
Both
b. If present, does lacrimal or lid condition cause scarring or disfigurement?
Yes
No
(If "Yes," complete Section V, Scarring and Disfigurement)
4. PTOSIS
a. If ptosis is present, indicate side affected:
Right
Left
Both
b. Is the Veteran's decrease in visual acuity or other visual impairment, if present, attributable to ptosis?
Yes
There is no decrease in visual acuity or other visual impairment
No
If "No," explain
c. Does the ptosis cause disfigurement?
Yes
(If "Yes," complete Section V, Scarring and Disfigurement)
No
5. CONJUNCTIVITIS AND OTHER CONJUNCTIVAL CONDITIONS
a. Indicate type of conjunctivitis, activity and side affected (Check all that apply):
Trachomatous:
Nontrachomatous:
Active
Eye affected:
Right
Left
Both
Active
Eye affected:
Right
Left
Both
Inactive
Eye affected:
Right
Left
Both
Inactive
Eye affected:
Right
Left
Both
b. Indicate the Veteran's other conjunctival conditions, if any (Check all that apply):
Pinguecula
Eye affected:
Right
Left
Both
Symblepharon
Eye affected:
Right
Left
Both
Other, describe:
Eye affected:
Right
Left
Both
c. Is the Veteran's decrease in visual acuity or other visual impairment, if present, attributable to any of the eye conditions checked above in this section?
Yes
There is no decrease in visual acuity or other visual impairment
No
If "No," explain
d. Does any eye condition identified in this section cause scarring or disfigurement?
Yes
No
(If "Yes," complete Section V, Scarring and Disfigurement)
6. CORNEAL CONDITIONS
a. Has the Veteran had a corneal transplant?
If "Yes," indicate side of transplant:
Yes
Right
No
Left
Both
Indicate residuals (Check all that apply):
Pain
Eye affected:
Right
Left
Both
Photophobia
Eye affected:
Right
Left
Both
Glare sensitivity
Eye affected:
Right
Left
Both
Other (Describe)
:
Eye affected:
b. Does the veteran have keratoconus?
If "Yes," indicate eye affected:
VA FORM 21-0960N-2, JAN 2011
Right
Right
Yes
Left
Both
No
Left
Both
Page 5
SECTION IV: EYE CONDITIONS (Continued)
6. CORNEAL CONDITIONS (Continued)
c. Does the veteran have pterygium?
If "Yes," indicate eye affected:
Yes
Right
No
Left
Both
d. Does the veteran have another corneal condition that may result in an irregular cornea? (For example, pellucid marginal degeneration, irregular astigmatism from
corneal scar, post-laser refractive surgery, acne rosacea keratopathy, etc.)
Yes
No
If "Yes," specify corneal condition:
Eye affected:
Right
Left
Both
e. Is the Veteran's decrease in visual acuity or other visual impairment, if present, attributable to keratoconus or another corneal condition, if present?
Yes
No
There is no decrease in visual acuity or other visual impairment
(If "Yes," specify corneal condition responsible for visual impairment)
(If "No," explain)
f. Does any eye condition identified in this section cause scarring or disfigurement?
Yes
(If "Yes," complete Section V, Scarring and Disfigurement)
No
7. CATARACT AND OTHER LENS CONDITIONS
a. Indicate cataract condition:
Preoperative (cataract is present)
Eye affected:
Right
Left
Both
Postoperative (cataract has been removed)
Eye affected:
Right
Left
Both
Is there a replacement intraocular lens?
Yes
If "Yes," indicate eye:
Left
Right
b. Is there aphakia or dislocation of the crystalline lens?
If "Yes," indicate eye:
Right
No
Both
Yes
Left
No
Both
c. Is the Veteran's decrease in visual acuity or other visual impairment, if present, attributable to any of the eye conditions checked above in this section?
Yes
No
There is no decrease in visual acuity or other visual impairment
If "Yes," specify condition in this section responsible for visual impairment:
If "No," explain:
8. INFLAMMATORY EYE CONDITIONS AND/OR INJURIES
a. Indicate the Veteran's condition and eye affected:
Choroidopathy (including uveitis, iritis, cyclitis, and choroiditis)
Right
Keratopathy
Right
Left
Both
Scleritis
Right
Left
Both
Intraocular hemorrhage
Right
Left
Both
Unhealed eye injury
Right
Left
Both
Other (Describe)
Left
Both
:
b. Is the Veteran's decrease in visual acuity or other visual impairment, if present, attributable to any eye condition and/or injury checked above in this section?
Yes
No
There is no decrease in visual acuity or other visual impairment
If "Yes," specify inflammatory or traumatic condition responsible for visual impairment
If "No," explain:
c. Does any eye condition identified in this section cause scarring or disfigurement?
Yes
(If "Yes," complete Section V, Scarring and Disfigurement)
No
9. GLAUCOMA
a. Specify the type of glaucoma:
Angle-closure
Eye affected:
Right
Left
Both
Open-angle
Eye affected:
Right
Left
Both
Other, specify type (For example, neovascular,phakolytic, etc.) :
Eye affected:
b. Does the glaucoma require continuous medication for treatment?
If "Yes," indicate eye affected
Right
Left
Yes
Right
Left
Both
No
Both
List medication(s) used for treatment of glaucoma:
c. Is the Veteran's decrease in visual acuity or other visual impairment, if present, attributable to glaucoma?
Yes
No
There is no decrease in visual acuity or other visual impairment
If "No," explain:
d. Does any glaucoma condition identified in this section cause scarring or disfigurement?
VA FORM 21-0960N-2, JAN 2011
Yes
No
(If "Yes," complete Section V, Scarring and Disfigurement)
Page 6
SECTION IV: EYE CONDITIONS (Continued)
10. OPTIC NEUROPATHY AND OTHER DISC CONDITIONS
a. Indicate the optic neuropathy and other disc conditions, and eye affected (check all that apply):
Drusen of optic disc
Right
Left
Both
Ischemic optic neuropathy
Right
Left
Both
Nutritional optic neuropathy
Right
Left
Both
Optic atrophy
Right
Left
Both
Other (Describe)
Right
Left
Both
b.Is the Veteran's decrease in visual acuity or other visual impairment, if present, attributable to any of the eye conditions checked in Item 10?
Yes
No
There is no decrease in visual acuity or other visual impairment
If "Yes," specify optic neuropathy or disc condition responsible for visual impairment:
If "No," explain:
11. RETINAL CONDITIONS
a. Indicate retinal condition and eye affected (check all that apply):
Retinopathy
Right
Left
Both
Maculopathy
Right
Left
Both
Detached retina
Right
Left
Both
Retinal hemorrhage
Right
Left
Both
Centrally located retinal scars, atrophy or
irregularities in either eye that result in an
irregular, duplicated, enlarged or
diminished image in either eye
Right
Left
Both
b.Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to any of the eye conditions checked in Item 11A?
Yes
No
There is no decrease in visual acuity or other visual impairment
If "Yes, specify retinal condition responsible for visual impairment:
If "No," explain:
12. NEUROLOGIC EYE CONDITIONS
a. Indicate the Veteran's neurologic eye condition/disorder:
Nystagmus
If checked,is nystagmus etiology central?
Yes
No
Paresis/paralysis of 3rd cranial nerve (oculomotor)
Eye affected:
Right
Left
Both
Paresis/paralysis of 4th cranial nerve (trochlear)
Eye affected:
Right
Left
Both
Paresis/paralysis of 6th cranial nerve (abducens)
Eye affected:
Right
Left
Both
Paresis/paralysis of 7th cranial nerve (facial, Bell's palsy) Eye affected:
Right
Left
Both
Eye condition due to cerebrovascular accident (CVA)
Eye affected:
Right
Left
Both
Eye affected:
Right
Left
Both
If checked, specify eye condition attributable to CVA:
Eye condition due to demyelinating disease
If checked, specify eye condition attributable to demyelinating disease:
Optic neuritis
Eye affected:
Right
Left
Both
Eye condition due to intracranial mass/tumor
Eye affected:
Right
Left
Both
Right
Left
Both
If checked, specify eye condition attributable to intracranial mass/tumor:
Eye condition due to Traumatic brain injury (TBI)
Eye affected:
If checked, specify eye condition attributable to TBI:
Other
If checked, specify neurologic eye condition/disorder and name the underlying neurologic condition (for example, Alzheimer's disease, JakobCreutzfeldt disease, etc.):
Eye affected:
Right
Left
Both
b.Is the Veteran's decrease in visual acuity or other visual impairment, if present, attributable to any of the neurologic eye conditions checked above in this section?
Yes
No
There is no decrease in visual acuity or other visual impairment
If "Yes," specify condition responsible for visual impairment:
If "No," explain:
VA FORM 21-0960N-2, JAN 2011
Page 7
SECTION IV: EYE CONDITIONS (Continued)
13. TUMORS AND NEOPLASMS
Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section?
Yes
No
(If "Yes," complete Items 13A thru 13E)
a. Is the neoplasm:
Benign
Malignant
b. 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
If checked, describe:
Surgery
Date(s) of surgery:
Radiation therapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Antineoplastic chemotherapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Other therapeutic procedure
If checked, describe procedure:
Date of most recent procedure:
Other therapeutic treatment
If checked, describe treatment:
Date of completion of treatment or anticipated date of completion:
c. 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 in Item 13B?
Yes
No
If "Yes," list residual conditions and complications (Brief summary):
d. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in Section I, Diagnosis, describe using the format in Item 13B:
e. Do any benign or malignant neoplasms or metastases identified in this section cause scarring or disfigurement?
Yes
No
If "Yes," complete Section V, Scarring and Disfigurement.
14. OTHER EYE CONDITIONS, PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
No
Does the veteran have any other eye conditions, pertinent physical findings, complications, conditions, signs
Yes
and/or symptoms related to the condition at hand?
If "Yes," describe:
VA FORM 21-0960N-2, JAN 2011
Page 8
SECTION V: SCARRING AND DISFIGUREMENT
Does the Veteran have scarring or disfigurement attributable to any eye condition?
Yes
No
If "Yes," indicate scar attributes (Check all that apply):
Scar at least one-quarter inch (0.6 cm.) wide at widest part
Surface contour of scar elevated or depressed on palpation (or inspection in the case of sclera)
Scar adherent to underlying tissue (including eyelids adherent to scleral tissue)
Visible or palpable tissue loss
Gross distortion or asymmetry of one feature or paired set of features (eyes)
For all checked conditions, describe scarring and/or disfigurement:
NOTE: If possible, include color photographs with any report of scarring or disfigurement.
SECTION VI: INCAPACITATING EPISODES
NOTE: For VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other
healthcare provider (For example, temporary bed rest required for a retinal condition.)
During the past 12 months, has the Veteran had any incapacitating episodes attributable to any eye conditions?
Yes
No
If "Yes," specify the eye condition(s) causing incapacitating episodes:
Describe how the eye condition(s) caused incapacitating episodes:
Provide the total duration for the incapacitating episodes for all incapacitating conditions over the past 12 months:
Less than 1 week
At least 1 week but less than 2 weeks
At least 2 weeks but less than 4 weeks
At least 4 weeks but less than 6 weeks
At least 6 weeks
VA FORM 21-0960N-2, JAN 2011
Page 9
SECTION VII: FUNCTIONAL IMPACT AND REMARKS
1. FUNCTIONAL IMPACT
Does the veteran's eye condition(s) impact his or her ability to work?
Yes
No
If "Yes," describe the impact of each of the veteran's eye condition(s), providing one or more examples:
2. REMARKS, IF ANY
SECTION VIII - OPTOMETRIST/PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION: To the best of my knowledge, the information contained herein is accurate, complete and current.
1B. OPTOMETRIST/PSYSICIAN PRINTED NAME
1A. OPTOMETRIST/PSYSICIAN SIGNATURE
1D. OPTOMETRIST/PSYSICIAN PHONE AND FAX
NUMBERS
1E. STATE OF LICENSURE
1C. DATE SIGNED
1F. OPTOMETRIST/PSYSICIAN LICENSE
NUMBER
1G. OPTOMETRIST/PSYSICIAN 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, 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 45 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 21-0960N-2, JAN 2011
Page 10
| File Type | application/pdf |
| File Title | VA Form 21-0960M-12 |
| Subject | Shoulder and Arm Conditions - Disability Benefits Questionnaire |
| Author | N. Kessinger |
| File Modified | 2011-12-30 |
| File Created | 2011-12-16 |