VA Form 21-0960N-2 Eye Conditions DBQ

OMB Approved No. 2900-XXXX
Respondent Burden: 45 minutes

EYE CONDITIONS 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.
NOTE - This examination must be conducted by a licensed optometrist or by a licensed ophthalmologist. The examiner must identify the disease, injury or other
pathologic process responsible for any decrease in visual acuity or other visual impairment found. For VA purposes, examinations of visual fields and/or muscle function
will be conducted ONLY when there is a medical indication of disease or injury that may be associated with visual field defect and/or impaired muscle [LA1] function.
Unless medically contraindicated, the fundus must be examined with the claimant's pupils dilated.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN EYE CONDITION?
YES

NO

(If "No," complete Item 1B)

(If "Yes," complete Item 1C)

1B. PROVIDE RATIONALE (veteran does not currently have any known eye conditions)

1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO EYE CONDITION(S)
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1D. IF ADDITIONAL DIAGNOSES THAT PERTAIN TO EYE CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S CURRENT EYE CONDITION(S) (brief summary):

SECTION III - ANATOMICAL LOSS AND/OR LIGHT PERCEPTION ONLY
3A. DOES THE VETERAN HAVE ANATOMICAL LOSS OF EITHER EYE?
YES

NO
RIGHT

(If "Yes," indicate eye(s))
LEFT

BOTH

3B. IS THE VETERAN'S VISION LIMITED TO NO MORE THAN LIGHT PERCEPTION ONLY IN EITHER EYE?
YES

NO
RIGHT

(If "Yes," indicate for which eye(s) the veteran's vision is limited to no more than light perception)
LEFT

BOTH

3C. IS THE VETERAN ABLE TO RECOGNIZE TEST LETTERS AT 1 FOOT OR CLOSER?
YES

NO
RIGHT

(If "No," indicate with which eye(s) the veteran is unable to recognize test letters at 1 foot or closer)
LEFT

BOTH

3D. IS THE VETERAN ABLE TO PERCEIVE OBJECTS, HAND MOVEMENTS, OR COUNT FINGERS AT 3 FEET?
YES

NO
RIGHT

VA FORM
JAN 2011

(If "No," indicate with which eye(s) the veteran is unable to perceive objects, hand movements, or count fingers at 3 feet)
LEFT

21-0960N-2

BOTH

Page 1

SECTION IV - EXAMINATION
4-1 VISUAL ACUITY
NOTE - Examination of visual acuity must include the central uncorrected and its equivalent corrected visual acuity for distance and near vision using Snellen's test
type or its equivalent. Visual acuity should not be determined with eccentric fixation or viewing. For VA purposes, visual acuity is evaluated according to the lines on
the Snellen chart or its equivalent.
NOTE - If assessment of the veteran's visual acuity falls between two lines on the Snellen chart, round up to the higher (worse) level (poorer vision) for answers 4-1(A)
through 4-1(D) below. (For example, 20/60 would be reported as 20/70; 20/80 would be reported as 20/100, etc.
A. Uncorrected near:
RIGHT:

5/200*

20/400

15/200*

20/200

20/100

20/70

20/50

20/40 or better

LEFT:

5/200*

20/400

15/200*

20/200

20/100

20/70

20/50

20/40 or better

B. Uncorrected distance:
RIGHT:

5/200*

20/400

15/200*

20/200

20/100

20/70

20/50

20/40 or better

LEFT:

5/200*

20/400

15/200*

20/200

20/100

20/70

20/50

20/40 or better

C. Corrected near:
RIGHT:

5/200*

20/400

15/200*

20/200

20/100

20/70

20/50

20/40 or better

LEFT:

5/200*

20/400

15/200*

20/200

20/100

20/70

20/50

20/40 or better

D. Corrected distance:
RIGHT:

5/200*

20/400

15/200*

20/200

20/100

20/70

20/50

20/40 or better

LEFT:

5/200*

20/400

15/200*

20/200

20/100

20/70

20/50

20/40 or better

* The measurement of 5/200 and 15/200 visual acuity may be accomplished through several methods, such as by having the patient/veteran walk up to
the 20/200 Snellen test type chart at 5 feet and 15 feet respectively or by using another Snellen test type or its equivalent chart to
measure visual acuity at comparable distances.
E. Was the corrected visual acuity determined with standard spectacle correction (e.g., phoropter or trial frame exam)?
Yes

No

F. Does the veteran customarily wear contact lenses to correct for a corneal irregularity?
Yes

No

(If "Yes," was the corrected visual acuity determined with habitual contact lens correction in place and standard spectacle correction over refraction?)
Yes

No

(If "No," explain):

G. Does the veteran have legal (statutory) blindness (visual acuity of 20/200 or less in the better eye with use of a correcting lens) based upon visual acuity loss?
Yes

No

4-2 VISUAL ACUITY DIFFERENCES
NOTE - For VA purposes, in any case where the examiner reports that there is a difference equal of two or more lines on the Snellen test type chart or its equivalent
between near and distance corrected vision, with the near vision being worse, the examiner must provide at least 2 recordings of corrected near and distance vision and
explain the reason for the difference.
A. Is there a difference equal of two or more lines on the Snellen test type chart or its equivalent between near and distance corrected vision,
with the near vision being worse?
Yes

No

(If "Yes," explain reason for the difference):

B. Does the lens required to correct distance vision in the poorer eye differ by more than 3 diopters from the lens required to correct distance vision in the better eye?
Yes

No

(If "Yes," explain reason for the difference):

C. If the answer to 4-2(A) or 4-2(B) is yes, provide a second recording of corrected near and distance vision
Second recording of corrected near vision:
5/200*
20/400
RIGHT:
15/200*

20/200

20/100

20/70

20/50

20/40 or better

15/200*

20/200

20/100

20/70

20/50

20/40 or better

Second recording of corrected distance vision:
5/200*
20/400
RIGHT:
15/200*

20/200

20/100

20/70

20/50

20/40 or better

20/200

20/100

20/70

20/50

20/40 or better

LEFT:

LEFT:

5/200*

5/200*

20/400

20/400

VA FORM 21-0960N-2, JAN 2011

15/200*

Page 2

SECTION IV - EXAMINATION (Continued)
4-3 PUPILS
Pupils:
Pupils are round and reactive to light
Afferent papillary defect, describe [LA2]:
Other, describe:

Pupil diameter:

Right:

mm

Left:

mm

4-4 DIPLOPIA
A. Does the veteran have diplopia?
Yes

No

(If "Yes," provide etiology (such as traumatic injury, thyroid eye disease, myasthenia gravis, etc.)

(If "Yes," chart the areas of diplopia on a Goldman perimeter chart that identifies the four major quadrants (upward, downward, left lateral and right lateral) and the
central field (20 degrees or less) and include the chart with this questionnaire)
Include the results from the Goldman perimeter chart below:
Right eye:
Up:

degrees

Down:

degrees

Right lateral:

degrees

Left lateral:

degrees

Left eye:
Up:

degrees

Down:

degrees

Right lateral:

degrees

Left lateral:

degrees

B. Is the diplopia occasional?
Yes

No

(If "Yes," indicate frequency of diplopia and most recent occurrence [LA3]):
C. Is the diplopia correctable with standard spectacle correction?
Yes

No

(If "No," is the diplopia correctable with standard spectacle correction that includes a special prismatic correction [LA4][LA5]?)
Yes

No

D. Is the veteran's diplopia secondary to a cranial nerve or extraocular muscle weakness [LA6]/paralysis?
Yes

No

(If "Yes," indicate cranial nerve(s), extraocular muscle(s) and side affected: (check all that apply))
3rd cranial nerve (oculomotor) paresis/paralysis

RIGHT

LEFT

BOTH

4th cranial nerve (trochlear) paresis/paralysis

RIGHT

LEFT

BOTH

6th cranial nerve (abducens) paresis/paralysis

RIGHT

LEFT

BOTH

Superior rectus

RIGHT

LEFT

BOTH

Medial rectus

RIGHT

LEFT

BOTH

Inferior rectus

RIGHT

LEFT

BOTH

Lateral rectus

RIGHT

LEFT

BOTH

Superior oblique

RIGHT

LEFT

BOTH

Inferior oblique

RIGHT

LEFT

BOTH

VA FORM 21-0960N-2, JAN 2011

Page 3

SECTION IV - EXAMINATION (Continued)
4-5 VISUAL FIELDS
A. Are visual fields intact to confrontation [LA7]?
Yes

No

B. Does the veteran have a visual field defect?
Yes

No

(If "Yes," complete 4-5(C) through 4-5(G) below):
NOTE - If the veteran has a visual field defect, examiners must perform visual field testing using either Goldmann kinetic perimetry or automated perimetry using
Humphrey Model 750, Octopus Model 101, or later versions of these perimetric devices with simulated kinetic Goldmann testing capability. Report the findings on a
standard Goldmann chart and include the chart with this questionnaire [LA8].
C. Was visual fields testing performed?
Yes
Results:

No
Using Goldmann's equivalent III/4e isopter
Date of exam:

Using Goldmann's equivalent IV/4e isopter [LA9]

Superior:

(normal 45)

Right:

degrees

Left:

degrees

Superior-temporal:

(normal 55)

Right:

degrees

Left:

degrees

Superior-nasal:

(normal 55)

Right:

degrees

Left:

degrees

Inferior:

(normal 65)

Right:

degrees

Left:

degrees

Inferior-temporal:

(normal 85)

Right:

degrees

Left:

degrees

Inferior-nasal:

(normal 50)

Right:

degrees

Left:

degrees

Nasal:

(normal 60)

Right:

degrees

Left:

degrees

Temporal:

(normal 85)

Right:

degrees

Left:

degrees

Left 0 degrees:

degrees

Single:
Right 0 degrees:

degrees
degrees

Right 90 degrees:

degrees

Left 90 degrees:

Right 180 degrees:

degrees

Left 180 degrees:

degrees

Right 270 degrees:

degrees

Left 270 degrees:

degrees

Double:
Right 0 degrees:

degrees

Right 90 degrees:

degrees

degrees

Left 0 degrees:

degrees

Left 90 degrees:

Right 180 degrees:

degrees

Left 180 degrees:

degrees

Right 270 degrees:

degrees

Left 270 degrees:

degrees

D. Does the veteran have contraction of a visual field?
Yes

No

(If "Yes," for VA purposes, calculate average concentric contraction of the visual field of each eye by measuring the remaining visual field in degrees at each of the 8 principal meridians,
adding them, and dividing the sum by 8)
Right average concentric contraction:
Left average concentric contraction:
E. Does the veteran have loss of a visual field?
Yes

No

(If "Yes," check all that apply and indicate side):
Homonymous hemianopsia

RIGHT

LEFT

BOTH

Loss of temporal half of visual field

RIGHT

LEFT

BOTH

Loss of nasal half of visual field

RIGHT

LEFT

BOTH

Loss of inferior half of visual field

RIGHT

LEFT

BOTH

Loss of superior half of visual field

RIGHT

LEFT

BOTH

Other (specify)

RIGHT

LEFT

BOTH

F. Does the veteran have a scotoma?
Yes

No

(If "Yes," check all that apply and indicate side):
Scotoma affecting at least 1/4 of the visual field

RIGHT

LEFT

BOTH

Centrally located scotoma

RIGHT

LEFT

BOTH

G. Does the veteran have legal (statutory) blindness (visual field diameter of 20 degrees or less in the better eye, even if the corrected visual acuity is 20/20)
based upon visual field loss?
Yes

No

VA FORM 21-0960N-2, JAN 2011

Page 4

SECTION IV - EXAMINATION (Continued)
4-6 TONOMETRY
Tonometry:
Applanation
Other, describe [LA11]:
Dilatation:

RIGHT

LEFT

BOTH

Time:

Tropicamide:

%

4-7 SLIT LAMP EXAM
All normal (check this box only if all physical exam findings, a-k, below are normal [LA12])
A. External exam/lids/lashes
Right:

Normal

Other, describe:

Left:

Normal

Other, describe:

Right:

Normal

Other, describe:

Left:

Normal

Other, describe:

Right:

Normal

Other, describe:

Left:

Normal

Other, describe:

B. Conjunctiva

C. Cornea

D. Anterior chamber
Right:

Normal

Other, describe:

Left:

Normal

Other, describe:

Right:

Normal

Other, describe:

Left:

Normal

Other, describe:

Right:

Normal

Other, describe:

Left:

Normal

Other, describe:

Right:

Normal

Other, describe:

Left:

Normal

Other, describe:

Right:

Normal

Other, describe:

Left:

Normal

Other, describe:

Right:

Normal

Other, describe:

Left:

Normal

Other, describe:

Right:

Normal

Other, describe:

Left:

Normal

Other, describe:

Right:

Normal

Other, describe:

Left:

Normal

Other, describe:

E. Iris

F. Lens

G. Fundus

H. Macula

I. Vessels

J. Vitreous

K. Periphery

A. Does the veteran have any of the following eye conditions?
Yes

No

SECTION V - EYE CONDITIONS

(If "No," proceed to Section VI)

(If "Yes," indicate the eye condition(s), checking all that apply)
(If checked complete 5-1(B))
Anatomical loss of eyelids and/or brows
(If checked complete 5-2(C))
Lacrimal gland and lid
(If checked complete 5-3(D))
Ptosis, in either or both eyes
(If checked complete 5-4(E))
Conjunctivitis and other conjunctival conditions
(If checked complete 5-5(F))
Corneal conditions
(If checked complete 5-6(G))
Inflammatory eye conditions/injuries
(If
checked
complete
5-7(H))
Glaucoma
(If checked complete 5-8(I))
Cataracts and lens conditions
(If checked complete 5-9(J))
Retinal eye conditions
(If checked complete 5-10(K))
(If checked complete 5-11(L))

Neurologic eye conditions
Neoplasms

Other eye condition(s) (specify)
VA FORM 21-0960N-2, JAN 2011

(If checked complete 5-12(M))
Page 5

SECTION V - EYE CONDITIONS (Continued)
5-1 ANATOMICAL LOSS OF EYELIDS AND/OR BROWS
B. Indicate the veteran's condition(s) and side affected
Partial or complete loss of eyelid(s)

RIGHT

LEFT

BOTH

Complete loss of eyebrows

RIGHT

LEFT

BOTH

Complete loss of eyelashes

RIGHT

LEFT

BOTH

Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to eyelid loss condition?
Yes

No

There is no decrease in visual acuity or other visual impairment

(If "No," explain):
If present, does eyelid loss cause scarring or disfigurement?
Yes

No

(If "Yes," complete scarring and disfigurement in Section VI)
5-2LACRIMAL GLAND AND LID CONDITIONS

C. Indicate the veteran's condition(s) and side affected (check all that apply)
Ectropion
RIGHT
LEFT
Entropion

LEFT

RIGHT

BOTH
BOTH

Lagophthalmos

RIGHT

LEFT

BOTH

Disorders of the lacrimal apparatus

RIGHT

LEFT

BOTH

(epiphora, dacryocystitis, etc.)

5-3 PTOSIS
D. If ptosis is present, indicate side affected:
RIGHT
LEFT
BOTH
Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to ptosis?
Yes

No

There is no decrease in visual acuity or other visual impairment

(If "No," explain):
Does the Ptosis loss cause disfigurement?
Yes

No

(If "Yes," complete scarring and disfigurement in Section VI)
5-4 CONJUNCTIVITIS AND OTHER CONJUNCTIVAL CONDITIONS

E. Indicate type of conjunctivitis, activity, and side affected (check all that apply):
Trachomatous
Active
Inactive
If present, indicate side affected

RIGHT

LEFT

BOTH

RIGHT

LEFT

BOTH

Nontrachomatous
Active
Inactive
If present, indicate side affected

Indicate the veteran's other conjunctival conditions, if any (check all that apply)
Pinguecula: if present, indicate side affected

RIGHT

LEFT

BOTH

Symblepharon: if present, indicate side affected

RIGHT

LEFT

BOTH

Other, describe:

RIGHT

LEFT

BOTH

Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to any of the eye conditions checked above in this section?
Yes

No

There is no decrease in visual acuity or other visual impairment

(If "No," explain):
Does this eye condition cause scarring or disfigurement?
Yes
No

(If "Yes," complete scarring and disfigurement in Section VI)
5-5 CORNEAL CONDITIONS
F. Has the veteran had a corneal transplant?
Yes
No

(If "Yes," indicate residuals and side affected (check all that apply)
Pain

RIGHT

LEFT

Photophobia

RIGHT

LEFT

BOTH

Glare sensitivity

RIGHT

LEFT

BOTH

Other, describe:

RIGHT

LEFT

BOTH

VA FORM 21-0960N-2, JAN 2011

BOTH

Page 6

SECTION V - EYE CONDITIONS (Continued)
5-5 CORNEAL CONDITIONS (Continued)
Does the veteran have keratoconus?

(If "Yes," indicate side affected )
Yes
No
Does the veteran have pterygium?

RIGHT

LEFT

BOTH

(If "Yes," indicate side affected )

RIGHT

LEFT

BOTH

Yes

No

Does the veteran have another corneal condition that may result in an irregular cornea? (For example, pellucid marginal degeneration, irregular astigmatism from corneal

scar, post-laser refractive surgery, acne rosacea keratopathy, etc.)
Yes

No

(If "Yes," specify corneal condition and indicate side affected)
RIGHT
LEFT
BOTH
Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to keratoconus or another corneal condition, if present?
Yes

There is no decrease in visual acuity or other visual impairment

No

(If "No," explain):
5-6 INFLAMMATORY EYE CONDITIONS AND/OR INJURIES
G. Indicate the veteran's condition and side affected:
Choroidopathy (including uveitis, iritis, cyclitis, and choroiditis)

RIGHT

LEFT

BOTH

Keratopathy

RIGHT

LEFT

BOTH

Scleritis

RIGHT

LEFT

BOTH

Intraocular hemorrhage

RIGHT

LEFT

BOTH

Unhealed eye injury

RIGHT

LEFT

BOTH

Other, describe:

RIGHT

LEFT

BOTH

Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to any eye condition and/or injury checked above?
Yes

No

There is no decrease in visual acuity or other visual impairment

(If "No," explain):
During the past 12 months, has the veteran had any incapacitating episodes attributable to any eye condition and/or injury checked [LA13] above?
Yes

No

(If "Yes," complete Section VII)
5-7 GLAUCOMA
H. Specify the type of glaucoma:
Angle-closure

Eye affected:

RIGHT

LEFT

BOTH

Open-angle

Eye affected:

RIGHT

LEFT

BOTH

Other, specify type (For example, neovascular,

Eye affected:

phakolytic, etc.)

RIGHT

LEFT

BOTH

Does the glaucoma require continuous medication for treatment?

(If "Yes," indicate side affected )
No
Yes
List medication(s) used for treatment of glaucoma:

RIGHT

LEFT

BOTH

Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to the type of glaucoma eye condition checked above?
Yes

No

There is no decrease in visual acuity or other visual impairment

(If "No," explain):
During the past 12 months, has the veteran had any incapacitating episodes attributable to the type of glaucoma eye condition checked above?
Yes

No

(If "Yes," complete Section VII)
5-8 CATARACT AND LENS CONDITIONS
I. Indicate cataract condition [LA14]
Non-operative (If a cataract is present, check

"non-operative" if surgery is not indicated at
the present time)

Preoperative (If a cataract is present, check

"preoperative" if surgery is not indicated at
the present time)
Postoperative (If "postoperative," is there a
replacement intraocular lens?)

If present, indicate eye affected:

RIGHT

LEFT

BOTH

If present, indicate eye affected:

RIGHT

LEFT

BOTH

If present, indicate eye affected:

RIGHT

LEFT

BOTH

Is there aphakia or dislocation of the crystalline lens?
Yes

No

(If "Yes," indicate side affected )

RIGHT

LEFT

BOTH

Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to the cataract or lens eye condition checked above?
Yes

No

There is no decrease in visual acuity or other visual impairment

(If "No," explain):
VA FORM 21-0960N-2, JAN 2011

Page 7

SECTION V - EYE CONDITIONS (Continued)
5-9 RETINOL CONDITIONS
J. Indicate cataract condition [LA14]:
Retinopathy

Specify side affected:

RIGHT

LEFT

BOTH

Maculopathy

Specify side affected:

RIGHT

LEFT

BOTH

Detached retina

Specify side affected:

RIGHT

LEFT

BOTH

Retinal hemorrhage

Specify side affected:

RIGHT

LEFT

BOTH

Unhealed eye injury

Specify side affected:

RIGHT

LEFT

BOTH

Centrally located retinal scars, atrophy
or irregularities in either eye that result in an
irregular, duplicated, enlarged or diminished
image in either eye

Specify side affected:

RIGHT

LEFT

BOTH

Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to the cataract eye condition checked above?
There is no decrease in visual acuity or other visual impairment

No

Yes

During the past 12 months, has the veteran had any incapacitating episodes attributable to the cataract eye condition checked above?
No

Yes

(If "Yes," complete Section VII)
5-10 NEUROLOGIC EYE CONDITIONS

K. Indicate the veteran's neurologic eye condition/disorder:
Nystagmus (If checked, specify type (For example central,
endpoint, pendular, etc.):

Specify side affected:

RIGHT

LEFT

BOTH

Paresis/paralysis of 3rd cranial nerve (oculomotor)

Specify side affected:

RIGHT

LEFT

BOTH

Paresis/paralysis of 4th cranial nerve (trochlear)

Specify side affected:

RIGHT

LEFT

BOTH

Paresis/paralysis of 6th cranial nerve (abducens)

Specify side affected:

RIGHT

LEFT

BOTH

Paresis/paralysis of 7th cranial nerve (facial, Bell's palsy)

Specify side affected:
Specify side affected:

RIGHT

LEFT

BOTH

RIGHT

LEFT

BOTH

Specify side affected:
Specify side affected:

RIGHT

LEFT

BOTH

RIGHT

LEFT

BOTH

Specify side affected:

RIGHT

LEFT

BOTH

Cerebrovascular accident (CVA) (If checked, specify location):
(For example: optic nerve, pre-chiasmal, post-chiasmal, optic tract,
ateral geniculate body, temporal lobe, parietal lobe, occipital lobe)
Optic neuritis
Intracranial mass/tumor (If checked, specify location):
(For example: optic nerve, pre-chiasmal, post-chiasmal, optic tract,
lateral geniculate body, temporal lobe, parietal lobe, occipital lobe)
Traumatic brain injury (TBI)
(If checked, describe effect of TBI on eye conditions):
Other, specify condition/disorder (For example, Alzheimer's disease,
Jakob-Creutzfeldt disease, etc.):

(If checked, specify location):
(For example: optic nerve, pre-chiasmal, chiasmal, post-chiasmal, optic
tract, lateral geniculate body, temporal lobe, parietal lobe, occipital
lobe))
Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to the neurologic condition/disorder checked above?
There is no decrease in visual acuity or other visual impairment

No

Yes

(If "No," explain):
During the past 12 months, has the veteran had any incapacitating episodes attributable to the neurologic eye condition checked above?
No

Yes

(If "Yes," complete Section VII)
5-11 NEOPLASMS

L. Does the veteran have an ophthalmic neoplasm?
Yes

No

(If "Yes," also complete VA Form 21-0960O-1, Tumors and Neoplasms Disability Benefits Questionnaire

5-12 OTHER EYE CONDITIONS, PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
M. Does the veteran have any other eye conditions, pertinent physical findings, complications, conditions, signs and/or symptoms?
Yes

No

(If "Yes," describe):

VA FORM 21-0960N-2, JAN 2011

Page 8

SECTION VI - SCARRING AND DISFIGUREMENT FOR EYE CONDITIONS

NOTE: Include color photographs with any report of scarring or disfigurement.
6. DOES THE VETERAN HAVE SCARRING ATTRIBUTABLE TO ANY EYE CONDITION?
YES

NO

(If "Yes," indicate scar attributes (check all that apply))
Scar at least one-quarter inch (0.6cm) wide at widest part
Surface contour of scar elevated or depressed on palpation (or inspection in the case of sclera)
Scar adherent to underlying tissue (including eyelids adherent to scleral tissue)
Visible or palpable tissue loss
Gross distortion or asymmetry of one feature or paired set of features (eyes)

SECTION VII - INCAPACITATING EPISODES

NOTE: For VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a
physician or other healthcare provider (For example, temporary bed rest required for a retinal condition).
7A. DURING THE PAST 12 MONTHS, HAS THE VETERAN HAD ANY INCAPACITATING EPISODES ATTRIBUTABLE TO ANY EYE CONDITIONS?
YES

NO

(If "Yes," specify the eye condition(s) causing incapacitating episodes [LA15]):
(If "Yes," describe how the eye condition(s) caused incapacitating episodes):
7B. PROVIDE THE TOTAL DURATION FOR THE INCAPACITATING EPISODES FOR ALL INCAPACITATING CONDITIONS OVER THE PAST 12 MONTHS
LESS THAN 1 WEEK
AT LEAST 1 WEEK BUT LESS THAN 2 WEEKS
AT LEAST 2 WEEKS BUT LESS THAN 4 WEEKS
AT LEAST 4 WEEKS BUT LESS THAN 6 WEEKS
AT LEAST 6 WEEKS

SECTION VIII - FUNCTIONAL IMPACT AND REMARKS
8. DOES THE VETERAN'S EYE CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO (If "Yes," describe the impact of each of the veteran's eye condition(s), providing one or more examples)

9. REMARKS (If any)

SECTION X - OPTOMETRIST/PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
10A. OPTOMETRIST/PHYSICIAN'S SIGNATURE

10D. OPTOMETRIST/PHYSICIAN'S PHONE NUMBER

10B. OPTOMETRIST/PHYSICIAN'S PRINTED NAME

10E. OPTOMETRIST/PHYSICIAN'S MEDICAL
LICENSE NUMBER

10C. DATE SIGNED

10F. OPTOMETRIST/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 45 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 21-0960N-2, JAN 2011

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