VA Form 21-0960C-1 Peripheral Nerves Conditions (Not including Diabetic Sen

OMB Control No. 2900-0779
Respondent Burden: 45 Minutes
Expiration Date: XX/XX/XXXX

Peripheral Nerves Conditions (Not Including Diabetic Sensory- Motor Peripheral
Neuropathy) 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. VA reserves the right to confirm the authenticity of ALL DBQs completed by
private health care providers.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE A PERIPHERAL NERVE CONDITION OR PERIPHERAL NEUROPATHY?
No (If "Yes," complete Item 1B)

Yes

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO A PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY:
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 A PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY, LIST USING ABOVE
FORMAT:

DEFINITIONS: For VA purposes, neuralgia indicates a condition characterized by a dull and intermittent pain of typical distribution so as to identify
the nerve, while neuritis is characterized by loss of reflexes, muscle atrophy, sensory disturbances and constant pain, at times excruciating.
SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S PERIPHERAL NERVE CONDITION (brief summary):

2B. DOMINANT HAND
Right

Left

Ambidextrous

SECTION III - SYMPTOMS
3A. Does the veteran have any symptoms attributable to any peripheral nerve conditions?
Yes

No

If yes, indicate symptoms' location and severity (check all that apply):
Constant pain (may be excruciating at times)
Right upper extremity:

None

Mild

Moderate

Severe

Left upper extremity:

None

Mild

Moderate

Severe

Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:
Intermittent pain (usually dull)

None

Mild

Moderate

Severe

Right upper extremity:

None

Mild

Moderate

Severe

Left upper extremity:

None

Mild

Moderate

Severe

Right lower extremity:

None

Mild

Moderate

Severe

None

Mild

Moderate

Severe

Left lower extremity:
Paresthesias and/or dysesthesias
Right upper extremity:

None

Mild

Moderate

Severe

Left upper extremity:

None

Mild

Moderate

Severe

Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

VA FORM
XXX XXXX

21-0960C-10

SUPERSEDES VA FORM 21-0960C-10, OCT 2012,
WHICH WILL NOT BE USED.

Page 1

SECTION III - SYMPTOMS (Continued)

3A. Does the veteran have any symptoms attributable to any peripheral nerve conditions? (Continued)
Numbness
Right upper extremity:

None

Mild

Moderate

Severe

Left upper extremity:

None

Mild

Moderate

Severe

Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

3B. Other symptoms (describe symptoms, location and severity):

SECTION IV - MUSCLE STRENGTH TESTING
4A. Rate strength according to the following scale:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
All normal
Elbow flexion:

Right:

5/5

4/5

3/5

2/5

1/5

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

Pinch
(thumb to index finger):

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

Knee extension:

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

Ankle plantar flexion:

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

Ankle dorsiflexion:

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

Elbow extension:
Wrist flexion:
Wrist extension:
Grip:

0/5

4B. Does the veteran have muscle atrophy?
Yes

No

If muscle atrophy is present, indicate location:
For each instance of muscle atrophy, provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk:
Normal side:

Atrophied side:

cm

cm

SECTION V - REFLEX EXAM
5. Rate deep tendon reflexes (DTRs) according to the following scale:
0 - Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
All normal
Biceps

Right:

0

1+

2+

3+

Left:

0

1+

2+

3+

4+

Triceps

Right:

0

1+

2+

3+

4+

Left:

0

1+

2+

3+

4+

Brachioradialis

Right:

0

1+

2+

3+

4+

Knee
Ankle

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+

VA FORM 21-0960C-10, XXX XXXX

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SECTION VI - SENSORY EXAM
6. Indicate results for sensation testing for light touch:
All normal
Right:

Normal

Decreased

Absent

Left:

Normal

Decreased

Absent

Inner/outer forearm (C6/T1):

Right:

Normal

Decreased

Absent

Left:

Normal

Decreased

Absent

Hand/fingers (C6-8):

Right:

Normal

Decreased

Absent

Left:

Normal

Decreased

Absent

Right:

Normal

Decreased

Absent

Left:

Normal

Decreased

Absent

Right:

Normal

Decreased

Absent

Left:

Normal

Decreased

Absent

Lower leg/ankle (L4/L5/S1):

Right:

Normal

Decreased

Absent

Left:

Normal

Decreased

Absent

Foot/toes (L5):

Right:

Normal

Decreased

Absent

Left:

Normal

Decreased

Absent

Shoulder area (C5):

Upper anterior thigh (L2):
Thigh/knee (L3/4):

Other sensory findings, if any:

SECTION VII - TROPHIC CHANGES
7. DOES THE VETERAN HAVE TROPHIC CHANGES (characterized by loss of extremity hair, smooth, shiny skin, etc.) ATTRIBUTABLE TO PERIPHERAL NEUROPATHY?
Yes

No

If yes, describe:

SECTION VIII - GAIT
8. IS THE VETERAN'S GAIT NORMAL?
Yes

No

If no, describe abnormal gait:

Provide etiology of abnormal gait:

SECTION IX - SPECIAL TESTS FOR MEDIAN NERVE
9. WERE SPECIAL TESTS INDICATED AND PERFORMED FOR MEDIAN NERVE EVALUATION?
Yes

No

If yes, indicate results:
Phalen's sign:

Tinel's sign:

Right:

Positive

Negative

Left:

Positive

Negative

Right:

Positive

Negative

Left:

Positive

Negative

SECTION X - NERVES AFFECTED: Severity Evaluation for Upper Extremity Nerves and Radicular Groups

Based on symptoms and findings from this exam, complete the following section to provide an estimation of the severity of the veteran's
peripheral neuropathy. This summary provides useful information for VA purposes.
NOTE: For VA purposes, the term “incomplete paralysis" indicates a degree of lost or impaired function substantially less than the
description of complete paralysis that is given with each nerve.
If the nerve is completely paralyzed, check the box for “complete paralysis.” If the nerve is not completely paralyzed, check the box for
“incomplete paralysis” and indicate severity. For VA purposes, when nerve impairment is wholly sensory, the evaluation should be mild,
or at most, moderate.
VA FORM 21-0960C-10, XXX XXXX

Page 3

SECTION X - NERVES AFFECTED: Severity Evaluation for Upper Extremity Nerves and Radicular Groups (Continued)
NOTE: INDICATE THE AFFECTED NERVES, SIDE AFFECTED AND SEVERITY OF CONDITION.
10A. Radial nerve (musculospiral nerve)
Note: Complete paralysis (hand and fingers drop, wrist and fingers flexed; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb or

make lateral movement of wrist; supination of hand, elbow extension and flexion weak, hand grip impaired)
Normal

Right:

Complete paralysis

Incomplete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Normal

Left:

Moderate

Severe
Complete paralysis

Incomplete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

10B. Median nerve
Note: Complete paralysis (hand inclined to the ulnar side, index and middle fingers extended, atrophy of thenar eminence, cannot make fist, defective opposition

of thumb, cannot flex distal phalanx of thumb; wrist flexion weak)
Normal

Right:

Complete paralysis

Incomplete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Normal

Left:

Moderate

Severe
Complete paralysis

Incomplete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

10C. Ulnar nerve
Note: Complete paralysis ("griffin claw" deformity, atrophy in dorsal interspaces, thenar and hypothenar eminences; cannot extend ring and little finger, cannot

spread fingers, cannot adduct the thumb; wrist flexion weakened)
Right:

Normal

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Left:

Normal

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

10D. Musculocutaneous nerve
Note: Complete paralysis (weakened flexion of elbow and supination of forearm)
Right:

Normal

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Left:

Normal

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

10E. Circumflex nerve
Note: Complete paralysis (innervates deltoid and teres minor; cannot abduct arm, outward rotation is weakened)
Right:

Normal

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Left:

Normal

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

10F. Long thoracic nerve
Note: Complete paralysis (inability to raise arm above shoulder level, winged scapula deformity)
Right:

Normal

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Left:

Normal

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
VA FORM 21-0960C-10, XXX XXXX

Moderate

Severe

Page 4

SECTION X - NERVES AFFECTED: Severity Evaluation for Upper Extremity Nerves and Radicular Groups (Continued)

10G. Upper radicular group (5th & 6th cervicals)

Note: Complete paralysis (all shoulder and elbow movements lost; hand and wrist movements not affected)
Normal

Right:

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Normal

Left:

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

10H. Middle radicular group
Note: Complete paralysis (adduction, abduction, rotation of arm, flexion of elbow and extension of wrist lost)
Normal

Right:

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Normal

Left:

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

10I. Lower radicular group
Note: Complete paralysis (intrinsic hand muscles, wrist and finger flexors paralyzed; substantial loss of use of hand)
Normal

Right:

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Normal

Left:

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

SECTION XI - NERVES AFFECTED: Severity Evaluation for Lower Extremity Nerves
Based on symptoms and findings from this exam, complete the following section to provide an estimation of the severity of the veteran's peripheral
neuropathy. This summary provides useful information for VA purposes.
NOTE: For VA purposes, the term “incomplete paralysis" indicates a degree of lost or impaired function substantially less than the description of complete
paralysis that is given with each nerve.
If the nerve is completely paralyzed, check the box for “complete paralysis.” If the nerve is not completely paralyzed, check the box for “incomplete
paralysis” and indicate severity. For VA purposes, when nerve impairment is wholly sensory, the evaluation should be mild, or at most, moderate.
NOTE: INDICATE AFFECTED NERVES, SIDE AFFECTED AND SEVERITY OF CONDITION.
11A. Sciatic nerve
Note: Complete paralysis (foot dangles and drops, no active movement of muscles below the knee, flexion of knee weakened or lost)
Right:

Normal

Incomplete paralysis

Complete paralysis

If incomplete paralysis is checked, indicate severity:
Mild
Left:

Normal

Moderate

Moderately Severe

Incomplete paralysis

Severe, with marked muscular atrophy

Complete paralysis

If incomplete paralysis is checked, indicate severity:
Mild

Moderate

Moderately Severe

Severe, with marked muscular atrophy

11B. External popliteal (common peroneal) nerve
Note: Complete paralysis (foot drop, cannot dorsiflex foot or extend toes; dorsum of foot and toes are numb)
Right:

Normal

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Left:

Normal

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

11C. Musculocutaneous (superficial peroneal) nerve
Note: Complete paralysis (eversion of foot weakened)
Right:

Normal

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
VA FORM 21-0960C-10, XXX XXXX

Moderate

Severe

Page 5

SECTION XI - NERVES AFFECTED: Severity Evaluation for Lower Extremity Nerves (Continued)
11C. Musculocutaneous (superficial peroneal) nerve (continued)
Normal

Left:

Complete paralysis

Incomplete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

11D. Anterior tibial (deep peroneal) nerve
Note: Complete paralysis (dorsiflexion of foot lost)
Normal

Right:

Complete paralysis

Incomplete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Normal

Left:

Moderate

Severe
Complete paralysis

Incomplete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

11E. Internal popliteal (tibial) nerve
Note: Complete paralysis (plantar flexion lost, frank adduction of foot impossible, flexion and separation of toes abolished; no muscle in sole can move; in lesions

of the nerve high in popliteal fossa, plantar flexion of foot is lost)
Normal

Right:

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Normal

Left:

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

11F. Posterior tibial nerve
Note: Complete paralysis (paralysis of all muscles of sole of foot, frequently with painful paralysis of a causalgic nature; loss of toe flexion; adduction weakened;

plantar flexion impaired)
Normal

Right:

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Normal

Left:

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

11G. Anterior crural (femoral) nerve
Note: Complete paralysis (paralysis of quadriceps extensor muscles)
Normal

Right:

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Normal

Left:

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

11H. Internal saphenous nerve
Normal

Right:

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Normal

Left:

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

11I. Obturator nerve
Right:

Normal

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
Left:

Normal

Moderate

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild
VA FORM 21-0960C-10, XXX XXXX

Moderate

Severe

Page 6

SECTION XI - NERVES AFFECTED: Severity Evaluation for Lower Extremity Nerves (Continued)
11J. External cutaneous nerve of the thigh
Normal

Right:

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Normal

Left:

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

11K. Illio-inguinal nerve
Normal

Right:

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Normal

Left:

Severe

Incomplete paralysis

Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild

Moderate

Severe

SECTION XII - ASSISTIVE DEVICES
12A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES 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

Frequency of use:

Occasional

Regular

Constant

Other:

12B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

SECTION XIII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
13. Due to peripheral nerve conditions, 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):

SECTION XIV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS

14A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I, DIAGNOSIS?
No
Yes
If yes, are any of the scars painful and/or unstable, or is the total area of all related scars greater than or equal to 39 square cm (6 square inches)?
Yes

No

If "Yes, also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire.
14B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDTIONS, SIGNS OR SYMPTOMS?
Yes

No

(If yes, describe (brief summary):

VA FORM 21-0960C-10, XXX XXXX

Page 7

SECTION XV - DIAGNOSTIC TESTING
NOTE: For the purpose of this examination, electromyography (EMG) studies are usually rarely required to diagnose specific peripheral nerve conditions in the
appropriate clinical setting. If EMG studies are in the medical record and reflect the veteran's current condition, repeat studies are not indicated.
15A. HAVE EMG STUDIES BEEN PERFORMED?
Yes

No

Extremities tested:
Right upper extremity

Results:

Normal

Abnormal

Date:

Left upper extremity

Results:

Normal

Abnormal

Date:

Right lower extremity

Results:

Normal

Abnormal

Date:

Left lower extremity

Results:

Normal

Abnormal

Date:

If abnormal, describe:
15B. 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 XVI - FUNCTIONAL IMPACT
16. DOES THE VETERAN'S PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY IMPACT HIS OR HER ABILITY TO WORK?
Yes

No

If yes, describe impact of each of the veteran's peripheral nerve and/or peripheral neuropathy condition(s), providing one or more examples:

SECTION XVII - REMARKS
17. REMARKS (If any)

SECTION XVIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
18A. PHYSICIAN'S SIGNATURE

18B. PHYSICIAN'S PRINTED NAME

18D. PHYSICIAN'S PHONE AND FAX NUMBER 18E. PHYSICIAN'S MEDICAL LICENSE NUMBER

18C. DATE SIGNED

18F. 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.benefits.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
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VA FORM 21-0960C-10, XXX XXXX

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