Form 21-4176 Report of Accidental Injury in Support of Claim for Comp

GENERAL INSTRUCTIONS FOR
REPORT OF ACCIDENTAL INJURY IN SUPPORT OF CLAIM FOR COMPENSATION OR PENSION/
STATEMENT OF WITNESS TO ACCIDENT
VA FORM 21-4176, PARTS A & B

WHAT PART SHOULD I COMPLETE?
If you are the veteran, complete only Part A "Report
of Accidental Injury in Support of Claim for
Compensation or Pension." If the accident was a
traffic accident, complete Sections I, II, and III of Part
A. For all other types of accidents, complete
Sections I and III of Part A.
If you are the witness, complete only Part B
"Statement of Witness to Injury."
Print all answers clearly. Answer questions as fully
as possible. If an answer is "none" or "unknown,"
write that. For additional space, attach a separate
sheet, indicating the item number to which the
answers apply.

HOW CAN I CONTACT VA IF I HAVE
QUESTIONS?
If you have questions about this form, how to fill it out, or
about benefits, you can contact VA in the following
ways:

.

By mail:
You can locate the address of the closest
regional office in your telephone book blue
pages under "United States Government,
Veterans."

.

By telephone:
Please call one of the following telephone
numbers
1-800-827-1000
1-800-829-4833 (Hearing Impaired TDD Line)

.

By internet:
https://iris.va.gov

PRIVACY ACT NOTICE: 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, Compensation, Pension,
Education and Rehabilitation Records - VA, published in the Federal Register. If you are the veteran, your obligation to respond is
required to obtain or retain benefits. If you are the witness, your obligation to respond is voluntary. The requested information is
considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered
confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other
agencies.
RESPONDENT BURDEN: We need this information to determine eligibility for compensation or pension benefits (38 U.S.C. 105, 1110,
1131, and 1521). 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.

VA FORM
OCT 2005

21-4176

EXISTING STOCKS OF VA FORM 21-4176, MAR 2003,
WILL BE USED.

OMB Control No. 2900-0104
Respondent Burden: 30 Mins.
1. VA FILE NUMBER

PART A

REPORT OF ACCIDENTAL INJURY IN SUPPORT OF CLAIM FOR COMPENSATION OR PENSION

2A. FIRST, MIDDLE, LAST NAME OF VETERAN

2B. COMPLETE MAILING ADDRESS

SECTION I

CIRCUMSTANCES OF ACCIDENT

3A. DATE AND TIME OF ACCIDENTAL
INJURY

3B. PLACE OF ACCIDENT (Identify location, such as house number, street, intersections, name or number of public highway,
name of nearest city, name and location of military post, foreign city and country, if applicable)

4A. DID THE ACCIDENT OCCUR WHILE
YOU WERE IN THE ARMED FORCES?

4B. MILITARY ORGANIZATION
OF WHICH YOU WERE A
MEMBER

YES

NO

(If "Yes," complete
Items 4B and 4C)

5A. WERE ALCOHOLIC INTOXICANTS,
NARCOTICS, DRUGS OR
MISCONDUCT OF ANY KIND ON THE
PART OF PERSONS CONCERNED
INVOLVED IN THIS ACCIDENT?
YES

NO

NO

5B. EXPLAIN FULLY ANSWER TO QUESTION IN ITEM 5A

(If "Yes," complete
Item 5B)

6A. DID CIVILIAN OR MILITARY POLICE
MAKE REPORT OF THE ACCIDENT?

YES

4C. AT TIME OF THE ACCIDENT, WERE YOU ON MILITARY DUTY, AUTHORIZED
PASS OR LEAVE, ABSENT WITHOUT LEAVE, ETC.? (Explain fully)

6B. FULL NAME AND COMPLETE MAILING ADDRESS OF CIVILIAN POLICE AND/OR MILITARY POLICE WHERE SUCH
REPORT MAY BE FILED

(If "Yes," complete
Item 6B)

7. FULL NAME AND MAILING ADDRESS OF THE PERSON IN WHOSE NAME THE REPORT WAS FILED

8. FULL DESCRIPTION OF HOW THE ACCIDENT OCCURRED, INCLUDING INJURIES YOU RECEIVED (If this was a traffic accident, complete also Items 9 through 24, Section II.
Complete Section III for any type of accident)

SECTION II

REPORT OF TRAFFIC ACCIDENT

INSTRUCTIONS: Identify one vehicle as the "first vehicle". If another vehicle was involved in the accident, identify it as the "second vehicle". If
you were riding in a vehicle involved in the accident, identify it as the "first vehicle".
9. TYPE OF FIRST VEHICLE

VA FORM
OCT 2005

21-4176

10. TYPE OF SECOND VEHICLE
(If any)

11A. WERE YOU?
DRIVER

11B. IN WHICH VEHICLE WERE YOU?
PASSENGER

EXISTING STOCKS OF VA FORM 21-4176, MAR 2003,
WILL BE USED.

12. IF PASSENGER, GIVE SEAT POSITION

13. IF PEDESTRIAN, WHAT WAS YOUR POSITION IN RELATION TO VEHICLE(S)?

14. DIRECTION OF TRAVEL OF FIRST VEHICLE

15. DIRECTION OF TRAVEL OF SECOND VEHICLE (If any)

16. APPROXIMATE SPEED OF FIRST VEHICLE

17. APPROXIMATE SPEED OF SECOND VEHICLE (If any)

18. WHAT WERE YOU DOING PRIOR TO AND AT TIME OF ACCIDENT?

19. TYPE OF ROADWAY (Concrete, asphalt, etc.)

20. CONDITION OF ROADWAY (Wet, dry, icy, etc.)

21. TRAFFIC CONTROLS (Traffic lights, road signs, obstructions, etc.)
22. WEATHER CONDITIONS (Clear, rain, snow, fog, etc.)

23. LIGHT (Dawn, daylight, dusk, darkness with artificial light, darkness with no light)

24. OTHER PERTINENT DETAILS

SECTION III - ALL ACCIDENTS (To be completed for any type of accident)
FULL NAME OF WITNESS

25. WITNESSES TO ACCIDENT
MAILING ADDRESS (Number and street, city, State and ZIP Code)

26. HISTORY OF TREATMENTS
TREAT- FULL NAME OF DOCTOR OR HOSPITAL FURNISHING
MENT
TREATMENT

MAILING ADDRESS
(Number and street, city, State and ZIP Code)

DATE
TREATED

FIRST
AID

SECOND

THIRD

CERTIFICATION: I hereby certify that the entries made herein are true and correct to the best of my knowledge and belief.
27. SIGNATURE OF VETERAN OR FIDUCIARY

28. DATE

WITNESS(ES) TO SIGNATURE OF VETERAN IF MADE BY "X" MARK

NOTE: Signature made by mark must be witnessed by two persons to whom the veteran is personally known and the signatures and addresses of the
witnesses must be entered below.
29A. SIGNATURE OF WITNESS

29B. ADDRESS OF WITNESS (Number and street, city, State and ZIP Code)

30A. SIGNATURE OF WITNESS

30B. ADDRESS OF WITNESS (Number and street, city, State and ZIP Code)

VA FORM 21-4176, OCT 2005

DETACH AND

RETURN TO VA

REGIONAL OFFICE
1. VETERAN’S FILE NUMBER

STATEMENT OF WITNESS TO ACCIDENT

PART B

NOTE: If you know the facts and circumstances relating to the injury received by the veteran, please complete the following
questions as fully as possible. Please sign and return the completed statement to the appropriate VA regional office. You may use
the reverse or attach additional sheets if necessary.
CALL THE NEAREST VA OFFICE TOLL- FREE WITH QUESTIONS: 1-800-827-1000 (HEARING IMPAIRED TDD 1-800-829-4833)
2A. FIRST, MIDDLE, LAST NAME OF WITNESS

2B. COMPLETE MAILING ADDRESS

3. DID YOU SEE THE ACCIDENT?

4. WHEN DID IT HAPPEN (Time and date)

YES
NO
5. WHERE DID IT HAPPEN (Identify location, such as house number, street, intersections, name or number of public highway, name and location of military
post, foreign city and country, if applicable)

6. WHERE WERE YOU WHEN THE ACCIDENT HAPPENED?

7. WHAT WAS THE VETERAN DOING PRIOR TO AND AT THE TIME OF THE ACCIDENT?

8. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED (If more space is needed, use reverse or attach a separate sheet)

9. IN YOUR OPINION, WHAT WAS THE CAUSE OF THE ACCIDENT? (If more space is needed, use reverse or attach a separate sheet)

10A. IN YOUR OPINION, WAS THE VETERAN
10B. EXPLAIN FULLY YOUR ANSWER TO ITEM 10A
UNDER THE INFLUENCE OF ANY
ALCOHOLIC INTOXICANTS, NARCOTICS
OR DRUGS WHEN THE ACCIDENT HAPPENED?

YES

NO

(If "Yes," complete 10B)

STATEMENT ON TRAFFIC ACCIDENT
INSTRUCTIONS - Identify one vehicle as the "first vehicle". If another vehicle was involved in the accident, identify it as the "second vehicle". If the
veteran was riding in one vehicle, identify it as the "first vehicle". If the veteran was not riding in a vehicle and you were in a vehicle involved in the
accident, identify that vehicle as the "first vehicle".
11. TYPE OF FIRST VEHICLE

12. TYPE OF SECOND VEHICLE (If any)

13A. WERE YOU

13B. IN WHICH VEHICLE WERE YOU?

14. IF PASSENGER, GIVE SEAT POSITION

DRIVER
PASSENGER
15. POSITION OF VETERAN (Driver, passenger, in first or second vehicle, pedestrian)

16. DIRECTION OF TRAVEL OF FIRST VEHICLE

17. DIRECTION OF TRAVEL OF SECOND VEHICLE (If any)

18. APPROXIMATE SPEED OF FIRST VEHICLE

19. APPROXIMATE SPEED OF SECOND VEHICLE (If any)

20. TYPE OF ROADWAY (Concrete, asphalt, etc.)

21. CONDITION OF ROADWAY (Wet, dry, icy, etc.)

22. TRAFFIC CONTROLS (Traffic lights, road signs, obstructions, etc.)
23. WEATHER CONDITIONS (Clear, rain, snow, fog, etc.)

24. LIGHT (Dawn, daylight, dusk, darkness with artificial light, darkness with no light)

25. OTHER WITNESS TO THIS ACCIDENT
NAME OF WITNESS

CERTIFICATION

MAILING ADDRESS (Number and street, city, State and ZIP Code)

I hereby certify that the entries made herein are true and correct to the best of my knowledge and belief.

26. DATE

VA FORM 21-4176, OCT 2005

27. SIGNATURE OF WITNESS