Form VA Form 21-0819 VA Form 21-0819 VA/DOD Joint Disability Evaluation Board Claim

OMB Approved No. 2900-XXXX
Respondent Burden: 30 minutes

DRAFT

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

VA/DOD JOINT DISABILITY EVALUATION BOARD CLAIM
IMPORTANT - Please read the Privacy Act and Respondent Burden on the back before
completing the form.
Section I: To be completed by Military Treatment Facility referring service member to Disability Evaluation Section
SERVICE MEMBER NAME (First, middle, last)

GRADE

COMPONENT

UNIT ADDRESS

SOCIAL SECURITY NUMBER

DATE OF BIRTH (MM,DD,YYYY)

SEX

MALE
DATE OF MILITARY MEDICAL EXAMINATION
(MM, DD, YYYY)

NAME OF REFERRING MILITARY TREATMENT FACILITY
(MTF)

FEMALE

DATE OF REFERRAL TO JOINT DISABILITY
EVALUATION BOARD (JDEB) (MM,DD,YYYY)

MEDICAL CONDITIONS TO BE CONSIDERED AS THE BASIS OF FITNESS FOR DUTY DETERMINATION:

PREPARED BY

DATE PREPARED

Section II: Tell us about yourself. Please provide a contact address. If you are on Temporary Duty, please indicate that on the VA
Form 21-4138, Statement in Support of Claim available on the internet at www.va.gov/vaforms.

1. Have you ever filed a claim with VA?
Yes

No

(If "Yes," provide file number)
(VA File Number)

2b. Please list the other name(s) you served
under

2a. Did you serve under another name?
Yes

(If "Yes," go to Item 2b)

No

(If "No," go to Item 3)

3. What is your address?

4. What are your telephone numbers?

Street address, rural route, or P.O. Box

City

State

Apt. number

ZIP Code

5. What is your E-mail address?

Country

6. I entered this current period of active
service on:
mo

day

Daytime

(

)

Evening

(

)

Cell phone

(

)

7. Place of entry:

yr

Section III: Tell us about your military service. Enter complete information for your service. Tell us about your reserve duty or
National Guard Duty.

8. Are you currently assigned to an
active reserve unit or National Guard Unit?
Yes

(If "Yes," provide date of
activation below)

No
mo
VA FORM
JUL 2007

day

21-0819 (Test)

yr

9a. What is the name and mailing address
of your current unit?

9b. What is the telephone
number of your
current unit?

10. Additional Conditions - (Do you have any disabling conditions, other than those referred for the fitness for duty
determination, that you feel were caused by, or aggravated by, your active military service?) Please list those
disabilities below:

Section IV: Give us your signature.

I certify and authorize the release of information.
I certify that the statements in this document are true and complete to the best of my knowledge. I authorize any
person or entity, including but not limited to any organization, service provider, employer, or government agency, to
give the Department of Veterans Affairs any information about me except protected health information, and I waive
any privilege that makes the information confidential.
11. Your signature (Do NOT print)

12. Date signed

Section V: Witnesses to Signature

13a. Signature of Witness (If claimant signed above using an "X")

13b. Printed name and address of witness

14a. Signature of Witness (If claimant signed above using an "X")

14b. Printed name and address of witness

PRIVACY ACT NOTICE: The form will be used to determine allowance to compensation benefits (38 U.S.C. 5101). The responses you submit are considered confidential (38
U.S.C. 5701). VA may disclose the information that you provide, including Social Security numbers, outside VA if the disclosure is authorized under the Privacy Act, including
the routine uses identified in the VA system of records, 58VA21/22 Compensation, Pension, Education, and Rehabilitation Records - VA. The requested information is
considered relevant and necessary to determine maximum benefits under the law. Information submitted is subject to verification through computer matching programs with
other agencies. VA may make a "routine use" disclosure for: civil or criminal law enforcement, congressional communications, epidemiological ore 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. Your obligation to respond is required in order to obtain or retain benefits. Information that you furnish may be
utilized in computer matching programs with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any
amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans Affairs.
Social Security information: You are required to provide the Social Security number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as
authorized under the Privacy Act, and, specifically may disclose them for purposes stated above.
Respondent Burden: We need this information to determine your eligibility for compensation. 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 www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to
send comments or suggestions about this form.