Form 21-0773 Global War on Terrorism Seriously Injured/ILL Servicemem

OMB Control No. 2900-0720
Respondent Burden: 30 minutes
Expiration Date: XXXXXXX
VA DATE STAMP
DO NOT WRITE IN THIS SPACE

GLOBAL WAR ON TERRORISM
SERIOUSLY INJURED/ILL SERVICEMEMBER/VETERAN WORKSHEET
IMPORTANT - Please read the Privacy Act and Respondent Burden Information on Page 3 before completing this form.
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You will either complete the form online or by hand. Please print the information request in ink, neatly, and legibly to help process the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

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

3. VA FILE NUMBER (If applicable)

Month

5. GENDER
MALE

Day

Year

6. VETERAN'S SERVICE NUMBER (If applicable)
FEMALE

7. PREFERRED MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

8. TELEPHONE NUMBER (Include Area Code)

9. E-MAIL ADDRESS (Optional)

SECTION II: INJURY/ILLNESS INFORMATION
11. REASON

10. INJURY/ILLNESS
VERY SERIOUS INJURY (VSI)

SPECIAL CATEGORY PERSON (SPC)

BATTLE INJURY

SERIOUS INJURY OR ILLNESS (SI)

NOT SERIOUSLY INJURED (NSI)

OTHER

NON BATTLE INJURY

ILLNESS

SECTION III: SERVICE INFORMATION
12. BRANCH OF SERVICE

13. THEATRE/OPERATION

ARMY

AIR FORCE

NAVY

MARINE CORP

COAST GUARD

OEF

OTHER

14. DATE RELEASED FROM ACTIVE DUTY (MM/DD/YYYY)
Month

Day

Year

OIF

15. NAME AND ADDRESS OF MILITARY/VA HOSPITAL (Street, City, State and ZIP Code)

16. ADMISSION DATE

17. WARD ROOM NUMBER

SECTION IV: NEXT OF KIN
18. NAME OF NEXT OF KIN AND RELATIONSHIP

19. ADDRESS OF NEXT OF KIN (Street, City, State and ZIP Code)

20. TELEPHONE NUMBER OF NEXT OF KIN (Include Area Code)

21. CELL PHONE NUMBER OF NEXT OF KIN (Include Area Code)

SECTION V: VA CONTACT INFORMATION
22. DATE OF INITIAL VA CONTACT

VA FORM
XXXX

21-0773

23. NAME OF VA CONTACT PERSON

SUPERSEDES VA FORM 21-0773, MAR 2015,
WHICH WILL BE USED.

24. TELEPHONE NO. OF VA CONTACT PERSON

(Include Area Code)

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VETERAN'S SOCIAL SECURITY NO.

SECTION VI: GENERAL INFORMATION

NOTE: Check all types that apply.
25. CLAIMS
CHECK

TYPE

26. SUPPORTING DOCUMENTS
DATE FILED

CHECK

VA FORM 21-526 COMPENSATION AND PENSION

DD 214 SEPARATION DOCUMENT

VA FORM 21-526B SUPPLEMENTAL CLAIM

MARRIAGE CERTIFICATE

VA FORM 21-526C PRE-DISCHARGE CLAIM

BIRTH CERTIFICATE(S)

VA FORM 21-526EZ APPLICATION FOR
COMPENSATION AND RELATED COMPENSATION
BENEFITS

DIVORCE DECREE(S)

VA FORM 21-4502 AUTOMOBILE GRANT

CHECK

TYPE

VA FORM 21-686C STATUS OF DEPENDENTS

VCAA

VA FORM 21-674C DEP. CHILD 18 OR OVER

STRS

CURRENT

VA FORM 21-509 DEPENDENT PARENT

MEB

VA FORM 22-1990 EDUCATION

PEB

VA FORM 22-5490 CH. 35 DEA

PERCENT %

VA FORM 26-1880 LOAN GUARANTY ELIGIBILITY

TYPE OF RETIREMENT/
SEPARATION

VA FORM 26-4555 ADAPTIVE HOUSING

MEB/PEB DOCUMENT PACKET

VA FORM 26-8937 VERIFICATION OF VA BENEFITS

OTHER (Specify)

VA FORM 28-1900 VOCATIONAL REHABILITATION
VA FORM 28-8832 COUNSELING

DATE RECEIVED

TYPE

COMPLETE

27. REFERRALS
CHECK

TYPE

VA FORM 29-4364 RH INSURANCE

VHA SOCIAL WORKER

VA FORM 10-8678 CLOTHING ALLOWANCE

VR&E

DD 1172 APPLICATION FOR ID CARD

VR&E TESTING PACKET ISSUED

Traumatic Injury Protection (TSGLI)

SERVICE ORGANIZATIONS

Veteran's Group Life Insurance (VGLI)

STATE VETERANS AFFAIRS

Servicemembers' Group Life Insurance (SGLI)

SSA

STATE OR LOCAL BENEFITS (Specify)

ROJ

OTHER (Specify)

TRANSITION PATIENT ADVOCATE

DATE REFERRED

FEDERAL RECOVERY COORDINATOR
OTHER (Specify)

27A. CONTACTS, SERVICE PROVIDED, OTHER INFORMATION, AND DATE FOR FUTURE VISIT/COMMUNICATION
DATE

VA FORM 21-0773, XXXX

DESCRIPTION

INITIALS

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VETERAN'S SOCIAL SECURITY NO.

27A. CONTACTS, SERVICE PROVIDED, OTHER INFORMATION, AND DATE FOR FUTURE VISIT/COMMUNICATION (Continued)
DATE

DESCRIPTION

INITIALS

28. REMARKS

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 the VA system of records, 58VA21/22/28
Compensation, Pension, Education, Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is
voluntary. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in
effect Prior to January 1, 1975, and still in effect.
RESPONDENT BURDEN: This form will be used as a checklist to ensure Veterans Service Representatives are providing OEF/OIF Seriously Injured/Ill
Servicemembers/veterans with information and/or forms for all VA benefits, in addition to SSA, State and local benefits. Title 38, United States Code, allows us to ask
for this information. We estimate that you will need an average of 30 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 http://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 21-0773, XXXX

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