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

OMB Approved No. 2900-0659
Respondent Burden: 1 hour 10 minutes
Expiration Date: XXXXXXXXX
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.

3A. DATE INCIDENT OCCURRED (Mo., day, yr.)

STRESSFUL INCIDENT NO. 1

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

3C. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,

CAVALRY, 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. Other sources of information also include
personal diaries or journals.
NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

VA FORM
XXX 2014

21-0781a

SUPERSEDES VA FORM 21-0781A, JAN 2014,
WHICH WILL NOT BE USED.

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STRESSFUL INCIDENT NO. 2

5A. DATE INCIDENT OCCURRED (Mo., day, yr.) 5B. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)

5C. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,

CAVALRY, SHIP)

5D. DATES OF UNIT ASSIGNMENT(Mo., day, yr.)
FROM

TO

5E. DESCRIPTION OF THE INCIDENT

6. 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. Other sources of information also include personal diaries or
journals.
NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

VA FORM 21-0781a, XXX 2014

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7. 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
sudden requests for a change in occupational series or duty assignment
increased use of leave without an apparent reason
changes in performance and performance evaluations
episodes of depression, panic attacks, or anxiety without an identifiable cause
increased or decreased use of prescription medications
increased use of over-the-counter medications

•
•
•
•
•
•
•

substance abuse such as alcohol or drugs
increased disregard for military or civilian authority
obsessive behavior such as overeating or undereating
pregnancy tests around the time of the incident
tests for HIV or sexually transmitted diseases
unexplained economic or social behavior changes
breakup of a primary relationship

I CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
8. SIGNATURE

9. DATE

10. 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 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 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.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 21-0781a, XXX 2014

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