DD Form 294 Application for a Review by the Physical Disability Boar

APPLICATION FOR A REVIEW BY THE PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)
OF THE RATING AWARDED ACCOMPANYING A MEDICAL SEPARATION
FROM THE ARMED FORCES OF THE UNITED STATES

OMB No. 0704-0453
OMB approval expires
XX/XX/XXXX

(Please read Instructions on Page 3 BEFORE completing this application.)

The public reporting burden for this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington
Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of
law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5014, Secretary of the Navy; 10 U.S.C. 8013, Secretary of the Air Force; 10 U.S.C 5043,
Commandant of the Marine Corps; U.S.C 93, Commandant of the Coast Guard; DoDI 6040.44, Lead DoD Component for the Physical Disability Board of
Review; 10 U.S.C. 1554(a); and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): Information is used to justify a fair and accurate reassessment of a veteran's Department of Defense Physical Evaluation Board
determination. Records provide all the necessary medical information to properly re-evaluate the military department's board determination and rating schedule.
ROUTINE USE(S): Law Enforcement, Congressional Inquiries, and Disclosures to the Office of Personnel Management
DISCLOSURE: Voluntary; however, failure to provide identifying information may impede processing of this application. The request for Social Security Number
is strictly to assure proper identification of the individual and appropriate records.

1. APPLICANT DATA (The person whose discharge is to be reviewed.) (Print or type all the information.)
a. BRANCH OF SERVICE (X one)

ARMY

b. NAME (Last, First, Middle Initial)

c. PAY GRADE (at time
of separation)

MARINE CORPS

NAVY

AIR FORCE

d. DATE OF SEPARATION (YYYYMMDD) (Must be
between 11 September 2001 and 31 December 2009
for review)

2. FINAL DISABILITY RATING AWARDED BY SERVICE FOR UNFITTING CONDITION(S) (X one)

0%

COAST GUARD

e. SOCIAL SECURITY NO.

10%

20%

3. ISSUES WHY THE RATING FOR THE CONDITION(S) WHICH RENDERED THE MEMBER UNFIT SHOULD BE CHANGED: (Continue in Item 12 if
necessary)

NEEDS DD67

4. IN SUPPORT OF THIS APPLICATION, THE FOLLOWING ATTACHED DOCUMENTS ARE SUBMITTED AS EVIDENCE: (Continue in Item 13 if necessary)

5. VETERANS AFFAIRS (VA) RATING INFORMATION (X one)
I have received a VA disability rating that includes the condition(s) for which I was found unfit.
If Yes, I have also been rated for other conditions (list all other conditions in Item 14).
6. VA CONSENT (X one)
To review my service disability rating, I

do

YES

NO

N/A

do not consent to release my VA records.
b. TELEPHONE NUMBER (Include Area Code)

7.a. COUNSEL/REPRESENTATIVE (If any) NAME (Last, First, Middle Initial) AND ADDRESS (See Item
7 of the instructions on Page 3 about counsel/representatives.)
c. E-MAIL

d. FAX NUMBER (Include Area Code)

8. APPLICANT MUST SIGN IN ITEM 11 BELOW. If the record in question is that of a deceased or incompetent person, LEGAL PROOF OF DEATH OR
INCOMPETENCY MUST ACCOMPANY THE APPLICATION. If the application is signed by other than the applicant, indicate the name (print)
and relationship by marking a box below.
SPOUSE

WIDOW

WIDOWER

NEXT OF KIN

LEGAL REPRESENTATIVE

OTHER

(Specify)

MAIL COMPLETED APPLICATIONS TO THE ADDRESS BELOW:
PHYSICAL DISABILITY BOARD OF REVIEW
SAF/MRBD
3351 CELMERS LANE
JBA NAF WASHINGTON, MD 20762-4390

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b. TELEPHONE NUMBER (Include Area Code)

9.a. CURRENT MAILING ADDRESS OF APPLICANT OR PERSON IN ITEM 8 ABOVE
(Forward notification of any change in address.)
c. CELL PHONE NUMBER (Include Area Code)

d. E-MAIL

10. I have read the attached instruction for this item and understand that by requesting this review I give up my right
under 10 U.S.C. 1552 to petition my Service's Board for Correction of Military/Naval Records to review and correct
the rating for the medical condition(s) which made me unfit. I make the foregoing statements, as part of my claim,
with full knowledge of the penalties involved for willfully making a false statement or claim. (U.S. Code, Title 18,
Sections 287 and 1001, provide that an individual shall be fined under this title or imprisoned not more than 5 years, or both.)
11.a. SIGNATURE (REQUIRED) (Applicant or person in item 8 above)

CASE NUMBER
(Do not write in this space)

b. DATE SIGNED
(YYYYMMDD)

12. CONTINUATION OF ITEM 3 (If applicable)

NEEDS DD67

13. CONTINUATION OF ITEM 4 (If applicable)

14. CONTINUATION OF ITEM 5 (If applicable)

15. REMARKS (If applicable)

MAIL COMPLETED APPLICATIONS TO THE ADDRESS BELOW:
PHYSICAL DISABILITY BOARD OF REVIEW
SAF/MRBD
3351 CELMERS LANE
JBA NAF WASHINGTON, MD 20762-4390

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INSTRUCTIONS FOR COMPLETING DD FORM 294
Please print or type all information. Items are self-explanatory unless otherwise noted below.
Item 1.b. Use the name which you served under while in the Armed Forces. If your name has been changed, then also include your current name after adding the
abbreviation "AKA". If the former member is deceased or incompetent, see Item 8.
Item 2. Indicate the percentage of disability rating for the condition(s) which rendered you unfit. If requested, the PDBR may review conditions considered, but
determined not unfitting by the Physical Evaluation Board. To receive the most thorough review, please indicate in block 3 of the DD Form 294 that you request
the PDBR “Review all Conditions.” Doing so will allow the PDBR to not only review your unfitting conditions, but also review those conditions found not unfitting.
Item 3. You may, but are not required to, explain why you believe the rating is inaccurate. If you make no assertion, your rating will still be reviewed for accuracy
and fairness.
Item 4. For verification of eligibility attach a copy of your DD Form 214, Copy 2 or NGB-22, if applicable. The PDBR will gather your service treatment records, a
copy of your Physical Evaluation Board records and with your consent in Item 6 a copy of your VA Rating Decision and Compensation and Pension examination
results from the DVA. In accordance with DoDI 6040.44, you will be afforded at least two weeks prior to a review of your rating to provide documentary evidence
outside DoD possession (including, for example, evidence from civilian medical providers).
Item 5. Indicate whether you have received a VA rating for the unfitting condition(s) and whether you have been rated for another condition(s). The PDBR will
consider the rating awarded by the VA for your unfitting condition(s) and compare it in reviewing your Service disability rating with particular attention to a VA
rating with an effective date within 12 months of your separation.
Item 6. This consent is required for the PDBR to gain access to your VA records. If you do not consent, the PDBR will review your disability rating, but will not
conduct the comparison discussed in Item 5 above.
Item 7.a. - d. Skip or enter N/A (not applicable) if you do not have a representative/counsel. If you later obtain the services of either, inform the Board
immediately. The military services do not provide counsel representation nor do they pay the cost of such representation. Contact your local VA office or Veterans
Service Organization for further information about other organizations that may assist you.
Item 8. If the former member is deceased or incompetent, the application may be submitted by the next of kin, a surviving spouse or a legal representative. Legal
proof of death or incompetency and satisfactory evidence of the relationship to the former member must accompany this application.

NEEDS DD67

Item 9.a. Indicate the address to be used for correspondence regarding this application. If you change this address while this application is pending, you should
notify the PDBR immediately. 9.d. Enter a current email address. Status updates and correspondence will be provided by email, when possible.
Item 10. By requesting a PDBR review, you are giving up your right under 10 U.S.C. 1552 to petition your Service's Board for Correction of Military/Naval Records
to subsequently review the rating for the medical condition(s) which rendered you unfit. The decision of the Secretary on this issue will be final. You may still ask
your Service Board for Correction of Military/Naval Records (BCMR/BCNR) to consider other issues including those related to your disability separation. If you
have previously filed with your Service BCMR/BCNR you may not request the PDBR review the same condition(s) considered by the BCMR/BCNR. If your filed
with your Service BCMR/BCNR prior to the implementation of DoDI 6040.44 (June 27, 2008), you may still request PDBR review of your disability rating.

COMPARISON - BCMR/BCNR VS. PDBR REVIEW OF RATING
CHARACTERISTIC

BCMR/BCNR

PDBR

Panel Composition

3 civilians in grade of GS-15 and above.

Review Authority

Medical separation 20% or less where member did not
May apply for review of military record, within three years of
retire finalized between 11 September 2001 and 30
error/injustice (may be waived in the interest of justice)
September 2009

Review Process

Application submitted, medical, personnel or legal
advisories, prepared and served on applicant with chance
to comment before panel review and vote.

Application submitted, then case summarized by PDBR
medical member (or other experts) for presentation to
PDBR before vote. Applicant can submit records from nonDod sources.

Panel Outcome

Recommendation or decision.

Recommendation only.

Burden of Proof

Member has the burden of proof to establish error or
injustice. There is a presumption of regularity.

Member need not allege anything, review accomplished
upon request.

Standards

Will correct errors in records and/or remove an injustice.

Rating reviewed for fairness and accuracy.

Impact of subsequent VA Rating

Within discretion of the Board.

Will compare VA rating with particular attention to one given
within 12 months.

3 military officers in grade of 05/06 (or civilian equivalents.)

Item 11.a. and b. A signature and date, entered by the applicant or people identified in Item 8, are required

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