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pdfOMB 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)
Page 1
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
Page 2
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
Page 3
File Type | application/pdf |
File Title | 21-0773 |
Subject | GLOBAL WAR ON TERRORISM SERIOUSLY INJURED / ILL SERVICEMEMBER / VETERAN WORKSHEET |
File Modified | 2017-03-31 |
File Created | 2017-03-31 |