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pdfOMB Approved No. 2900-XXXX
Respondent Burden: 15 minutes
SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE
PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION ON
REVERSE BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you
provide on this questionnaire as part of their evaluation in processing the Veteran's claim.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE A SCAR CONDITION?
YES
NO
(If "No," complete Item 1B)
(If "Yes," complete Item 1C)
1B. PROVIDE RATIONALE (e.g., veteran does not currently have any known scar conditions):
1C. Provide only diagnoses that pertain to scar conditions
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
1D. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SCARS, LIST USING ABOVE FORMAT:
INSTRUCTIONS - Provide all linear measurements in centimeters and area measurements in centimeters squared. For non-linear scars, measure the length and width at
their widest points. After measuring the scars, use the summary sections to provide the combined approximate total area for all scars in each region.
If scars are too numerous to count (for example, multiple scattered shrapnel wound scars, acne scarring or pseudofolliculitis barbae), indicate "TNTC" and provide
approximate combined total area.
NOTE - For VA purposes, superficial non-linear scars are those not associated with underlying soft tissue damage, while deep non-linear scars are associated with
underlying soft tissue damage.
SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including cause/origin and course) OF THE VETERAN'S SCAR CONDITION(S) (brief summary)
2B. ARE ANY OF THE SCARS PAINFUL?
YES
NO
(If, "Yes," specify location of painful scars and describe frequency and severity of pain):
2C. ARE ANY OF THE SCARS UNSTABLE, WITH FREQUENT LOSS OF COVERING OF SKIN OVER THE SCAR?
YES
NO
(If, "Yes," specify location of unstable scars and indicate frequency and severity of loss of covering of skin):
SECTION III - PHYSICAL EXAM FOR SCARS ON THE TRUNK AND EXTREMITIES
3. DOES THE VETERAN HAVE ANY SCARS ON THE TRUNK OR EXTREMITIES (regions other than the head, face or neck)?
YES
NO
(If, "Yes," complete the following sections 3-1 and 3-2)
3-1 - SUMMARY OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES
A. TOTAL NUMBER OF UNSTABLE OR PAINFUL SCARS
None
1
2
3
4
5 or more
B. SUPERFICIAL NON-LINEAR SCARS (check all that apply and provide approximate combined total area in centimeters squared for each affected anatomical region)
None
Right upper extremity:
Approximate total area:
cm2
Left upper extremity:
Approximate total area:
cm2
Right lower extremity:
Approximate total area:
cm2
Left lower extremity:
Approximate total area:
cm2
Anterior trunk:
Approximate total area:
cm2
Posterior trunk:
Approximate total area:
cm2
VA FORM
JAN 2011
21-0960F-1
Page 1
SECTION III - PHYSICAL EXAM FOR SCARS ON THE TRUNK AND EXTREMITIES
3. DOES THE VETERAN HAVE ANY SCARS ON THE TRUNK OR EXTREMITIES (regions other than the head, face or neck)?
YES
NO
(If, "Yes," complete the following sections 3-1 and 3-2)
3-1 - SUMMARY OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES
A. TOTAL NUMBER OF UNSTABLE OR PAINFUL SCARS
None
1
2
3
4
5 or more
B. SUPERFICIAL NON-LINEAR SCARS (check all that apply and provide approximate combined total area in centimeters squared for each affected anatomical region)
None
Right upper extremity:
Approximate total area:
cm2
Left upper extremity:
Approximate total area:
cm2
Right lower extremity:
Approximate total area:
cm2
Left lower extremity:
Approximate total area:
cm2
Anterior trunk:
Approximate total area:
cm2
Posterior trunk:
Approximate total area:
cm2
C. DEEP NON-LINEAR SCARS (check all that apply and provide approximate combined total area in centimeters squared for each affected anatomical region)
None
Right upper extremity:
Approximate total area:
cm2
Left upper extremity:
Approximate total area:
cm2
Right lower extremity:
Approximate total area:
cm2
Left lower extremity:
Approximate total area:
cm2
Anterior trunk:
Approximate total area:
cm2
Posterior trunk:
Approximate total area:
cm2
3-2 - DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES
NOTE - INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:
A. RIGHT UPPER EXTREMITY
Affected
Not affected
Specify location of scars on right upper extremity:
Indicate types of scars and provide measurements (check all that apply)
Linear
Length and width of each linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Superficial non-linear
Length and width of each superficial non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Deep non-linear
Length and width of each deep non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
B. LEFT UPPER EXTREMITY
Affected
Not affected
Specify location of scars on left upper extremity:
Indicate types of scars and provide measurements (check all that apply)
Linear
Length and width of each linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Superficial non-linear
Length and width of each superficial non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Deep non-linear
Length and width of each deep non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
VA FORM 21-0960F-1, JAN 2011
x
cm
Page 2
SECTION III - PHYSICAL EXAM FOR SCARS ON THE TRUNK AND EXTREMITIES (Continued)
3-2 - DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES (continued)
NOTE - INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:
C. RIGHT LOWER EXTREMITY
Affected
Not affected
Specify location of scars on right lower extremity:
Indicate types of scars and provide measurements (check all that apply)
Linear
Length and width of each linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Superficial non-linear
Length and width of each superficial non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Deep non-linear
Length and width of each deep non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
D. LEFT LOWER EXTREMITY
Affected
Not affected
Specify location of scars on left lower extremity:
Indicate types of scars and provide measurements (check all that apply)
Linear
Length and width of each linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Superficial non-linear
Length and width of each superficial non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Deep non-linear
Length and width of each deep non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
E. ANTERIOR TRUNK
Affected
Not affected
Specify location of scars on anterior trunk:
Indicate types of scars and provide measurements (check all that apply)
Linear
Length and width of each linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Superficial non-linear
Length and width of each superficial non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Deep non-linear
Length and width of each deep non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
VA FORM 21-0960F-1, JAN 2011
x
cm
Page 3
SECTION III - PHYSICAL EXAM FOR SCARS ON THE TRUNK AND EXTREMITIES (Continued)
3-2 - DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES (continued)
NOTE - INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:
F. POSTERIOR TRUNK
Affected
Not affected
Specify location of scars on posterior trunk:
Indicate types of scars and provide measurements (check all that apply)
Linear
Length and width of each linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Superficial non-linear
Length and width of each superficial non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Deep non-linear
Length and width of each deep non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
SECTION IV - PHYSICAL EXAM FOR SCARS ON THE HEAD, FACE AND NECK
4. DOES THE VETERAN HAVE ANY SCARS ON THE HEAD, FACE OR NECK?
YES
NO
(If "Yes," complete the following three sections 4-1, 4-2 and 4-3)
4-1 - SUMMARY OF SCAR FINDINGS FOR THE HEAD, FACE AND NECK
A. Total number of unstable or painful scars:
0
1
2
3
4
5 or more
B. Total number of scars 13 cm in length or longer:
0
1
2
3
4
5 or more
C. Total number of scars ,6cm in width or wider:
0
1
2
3
4
5 or more
D. Total number of scars that are elevated or depressed:
0
1
2
3
4
5 or more
E. Total number of scars that are adherent to underlying tissue:
0
1
2
3
4
5 or more
F. Approximate total area of head, face and neck covered by scars that are hypo- or hyperpigmented:
cm2
G. Approximate total area of head, face and neck covered by scars that have abnormal texture:
cm2
H. Approximate total area of head, face and neck covered by scars that have missing underlying soft tissue:
cm2
I. Approximate total area of head, face and neck covered by scars that are indurated and inflexible:
cm2
4-2 - DETAILS OF SCAR FINDINGS FOR THE HEAD, FACE AND NECK
A. INDICATE TYPES OF SCARS AND PROVIDE MEASUREMENTS (check all that apply)
Linear
Location of linear scars:
Length and width of each linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Superficial non-linear
Location of superficial non-linear scars:
Length and width of each superficial non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
Deep non-linear
Location of deep non-linear scars:
Length and width of each deep non-linear scar:
Scar # 1:
x
cm
Scar # 2:
x
cm
Scar # 3:
Scar # 4:
x
cm
Scar # 5:
x
cm
If additional scars, list using same format:
x
cm
B. ARE ANY OF THE SCARS ELEVATED, DEPRESSED, ADHERENT TO UNDERLYING TISSUE OR MISSING UNDERLYING SOFT TISSUE?
YES
NO
(If, "Yes," check all that apply)
Surface contour elevated on palpation (If checked, describe surface contour elevation for each affected scar):
Surface contour depressed on palpation (If checked, describe surface contour depression for each affected scar):
Scar adherent to underlying tissue (If checked, describe adherence to underlying tissue for each affected scar):
Underlying soft tissue missing (If checked, describe location of each affected scar):
VA FORM 21-0960F-1, JAN 2011
Page 4
SECTION IV - PHYSICAL EXAM FOR SCARS ON THE HEAD, FACE AND NECK (Continued)
4-2 - DETAILS OF SCAR FINDINGS FOR THE HEAD, FACE AND NECK (Continued)
C. DO ANY OF THE SCARS HAVE ABNORMAL PIGMENTATION OR TEXTURE?
YES
NO
(If, "Yes," check all that apply)
Surface contour elevated on palpation (If checked, describe surface contour elevation for each affected scar):
Surface contour depressed on palpation (If checked, describe surface contour depression for each affected scar):
Scar adherent to underlying tissue (If checked, describe adherence to underlying tissue for each affected scar):
Underlying soft tissue missing (If checked, describe location of each affected scar):
4-3 - DISTORTION OF FACIAL FEATURES AND TISSUE LOSS FOR THE HEAD, FACE AND NECK
A. DO ANY OF THE SCARS CAUSE GROSS DISTORTION OR ASYMMETRY OF FACIAL FEATURES OR VISIBLE OR PALPABLE TISSUE LOSS?
YES
NO
Nose
(If, "Yes," indicate features affected (check all that apply))
Chin
Forehead
Cheeks
Lips
Eyes (including eyelids) (If checked, specify):
Tissue loss/distortion of eyelid
Side:
Right
Tissue loss/distortion of eye
Side:
Right
Left
Left
Anatomical loss of eye
Side:
Right
Left
Complete loss of auricle
Side:
Right
Left
Deformity of auricle, with loss of
less than one-third the substance
Deformity of auricle, with loss of
one-third or more of the substance
Side:
Right
Left
Side:
Right
Left
Ears (auricles) (If checked, specify):
B. FOR ALL CHECKED FEATURES IN (4-3(A), PROVIDE A BRIEF DESCRIPTION OF THE TISSUE LOSS, GROSS DISTORTION AND/OR ASYMMETRY OF
FACIAL FEATURES:
SECTION X - LIMITATION OF FUNCTION/OTHER CONDITIONS
5A. DO ANY OF THE SCARS CAUSE LIMITATION OF FUNCTION?
YES
NO
(If, "Yes," indicate which scars are causing the limitation and describe the specific limitations):
5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS ASSOCIATED WITH
ANY SCAR CONDITIONS (such as muscle or nerve damage)?
YES
NO
(If "Yes," describe (brief summary))
VA FORM 21-0960F-1, JAN 2011
Page 5
SECTION VI - COLOR PHOTOGRAPHS
6. PROVIDE COLOR PHOTOGRAPHS, IF POSSIBLE, FOR ANY DISFIGURING CONDITIONS OF THE HEAD, FACE AND/OR NECK
PHOTOGRAPHS NOT INDICATED
PHOTOGRAPHS PROVIDED
PHOTOGRAPHS NOT AVAILABLE
SECTION VII - FUNCTIONAL IMPACT AND REMARKS
7. DOES THE VETERAN'S SCAR CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
(If "Yes," describe impact of each of the veteran's scar conditions, providing one or more examples)
8. REMARKS (If any)
SECTION VIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
9A. PHYSICIAN'S SIGNATURE
9D. PHYSICIAN'S PHONE NUMBER
9B. PHYSICIAN'S PRINTED NAME
9E. PHYSICIAN'S MEDICAL LICENSE NUMBER
9C. DATE SIGNED
9F. PHYSICIAN'S ADDRESS
NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
IMPORTANT - Physician please fax the completed form to
(VA Regional Office FAX No.)
NOTE - A list of VA Regional Office FAX Numbers can be found at www.vba.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
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, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is required to obtain or retain benefits. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are
properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an
individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. 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 entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that
you will need an average of 15 minutes to review the instructions, find the information, and complete the 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.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 21-0960F-1, JAN 2011
Page 6
| File Type | application/pdf |
| File Modified | 2011-02-28 |
| File Created | 2011-02-28 |