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

OMB Approved No. 2900-0659
Respondent Burden: 1 hour 10 minutes
Expiration Date: XXXXXX
VA DATE STAMP
DO NOT WRITE IN THIS SPACE

STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION FOR POSTTRAUMATIC STRESS DISORDER (PTSD) SECONDARY TO PERSONAL ASSAULT
IMPORTANT: If you or someone you know is in crisis, call the Veterans Crisis Line at 1-800-273-8255 and press 1,
or visit https://www.veteranscrisisline.net/ to chat online, or send a text message to 838255 to receive confidential
support 24 hours a day, 7 days a week, 365 days a year. Support for deaf and hard of hearing individuals is available.
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.
SECTION I: VETERAN'S IDENTIFICATION INFORMATION

NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.
1. VETERAN/BENEFICARY NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)

3. VA FILE NUMBER (If applicable)

Month

5. VETERAN'S SERVICE NUMBER (If applicable)

Day

Year

6. PREFERRED E-MAIL ADDRESS (Optional)

7A. PRIMARY TELEPHONE NUMBER (Include Area Code)

7B. SECONDARY TELEPHONE NUMBER (Include Area Code)

SECTION II: STRESSFUL INCIDENT(S)
8A. DATE FIRST INCIDENT OCCURRED (MM/DD/YYYY)
Month

Day

Year

8B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)
FROM:

Month

Day

Year

TO:

Month

Day

Year

8C. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)

8D. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION, CAVALRY, SHIP)

8E. DESCRIPTION OF THE INCIDENT

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.
VA FORM
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21-0781a

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

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VETERAN'S SOCIAL SECURITY NO.

9A. NAME

SECTION II: STRESSFUL INCIDENT(S) (Continued)
9B. ADDRESS

9C. NAME

9D. ADDRESS

9E. NAME

9F. ADDRESS

10A. DATE SECOND INCIDENT OCCURRED (MM,DD,YYYY)
Month
Day
Year
FROM: Month

10B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)
Day

Year

TO:

Month

Day

Year

10C. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)

10D. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION, CAVALRY, SHIP)

10E. DESCRIPTION OF THE INCIDENT

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.
11A. NAME

11B. ADDRESS

11C. NAME

11D. ADDRESS

11E. NAME

11 F. ADDRESS

VA FORM 21-0781a, XXXX

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VETERAN'S SOCIAL SECURITY NO.

SECTION II: STRESSFUL INCIDENT(S) (Continued)

12. Please provide in the space below any other information that you feel is important for us to know that may help your claim. The
following are some examples, of behavioral changes that you may have experienced 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

SECTION III: VETERAN SIGNATURE

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

14. DATE SIGNED (MM/DD/YYYY)

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, XXXX

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