Form 21-0964 Statement in Support for Disability and Related Compensa

INFORMATION AND INSTRUCTIONS FOR COMPLETING THE STATEMENT IN SUPPORT OF CLAIM FOR
DISABILITY COMPENSATION AND RELATED COMPENSATION BENEFITS DUE TO EXPOSURE
IMPORTANT - Please carefully read the information below to help you complete this form more quickly and accurately.
Some parts of the form also contain notes or specific instructions for completing that part.
Section I (Identification and Claim Information):
Item 1 - Please fill out your full name (Last, First, Middle)
Item 2 - Please fill in your Social Security Number
Item 3 - Please fill in your VA File Number (which may or may not be the same as your Social Security Number)
Section II (Exposure Type):
Item 4 - Please identify your type of exposure based on the claimed condition(s) noted on VA Form 21-526EZ,
Application for Disability Compensation and Related Compensation Benefits.
IMPORTANT - You must complete a separate VA Form 21-0964, Statement in Support of Claim for Disability
Compensation and Related Compensation Benefits Due to Exposure, for each type of exposure claimed.
Section III (Exposure Date(s) and Location(s)):
Item 5 - Please fill out the location(s) of your exposure. Please list by City/Town, State, and Country as applicable.
Item 6 - Please identify from the list below your claimed exposure. VA has identified several locations where exposure
may be conceded during certain timeframes and/or military duties. If you are claiming exposure to an occupational or
environmental hazard other than what is shown in the list below, please state what the exposure was and where it
occurred.
Asbestos
1. Mining
2. Milling
3. Work in shipyards
4. Insulation work
5. Demolition of old buildings
6. Carpentry and construction
7. Manufacture and service of friction products, such as clutch facing and brake lining
8. Manufacture and installation of products for roofing and flooring materials or asbestos cement sheet and pipe
products
9. Manufacture and installation of products for military equipment
10. Other [Please fill in the blank]
Cold Weather
1. Battle of the Bulge during World War II (WWII)
2. Battle of the Chosin Reservoir in Korean Conflict
3. Other [Please fill in blank]
Gulf Wars and Other Geographical Locations Environmental Hazard
Operation Desert Shield/ Storm:
1. Smoke and particles from multiple Kuwait oil well fires
2. Daily ingestion of anti-nerve gas pills
3. Inhalation of fine-grain sand particles in Iraq and Kuwait
4. Other [fill in blank]
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Gulf Wars and Other Geographical Locations Environmental Hazard (Continued)
Operation Enduring Freedom/ Iraqi Freedom:
1. Large burn pits throughout Iraq, Afghanistan, or Djibouti on the Horn of Africa
2. Large sulfur fire at Mishraq State Sulfur Mine near Mosul, Iraq
3. Hexavalent chromium exposure at the Qarmat Ali Water Treatment Plant in Basrah, Iraq
4. Inhalation of fine-grain sand particles in Iraq, Afghanistan, and Djibouti
5. Particulate matter in Iraq, Afghanistan, and Djibouti
6. Other [fill in blank]
Other Geographic Locations:
1. Pollutants from a waste incinerator near the Naval Air Facility (NAF) at Atsugi, Japan
2. Other [fill in blank]
Herbicides (i.e. Agent Orange)
1. Vietnam
2. Korean Demilitarized Zone
3. Thailand
4. Other [fill in blank]
Ionizing Radiation
1. Internment as a prisoner of war (POW) in Japan between August 6, 1945, to July 1, 1946
2. Presence in VA-defined Hiroshima or Nagasaki area during American occupation of Japan following World
War II
3. Participation in atmospheric nuclear weapons testing
4. Participated in underground nuclear weapons testing at Amchitka Island, Alaska prior to January 1, 1974
5. Assignment to a gaseous diffusion plant
6. Served in a capacity which, if performed as an employee of the Department of Energy, would qualify the
individual for inclusion as a member of the Special Exposure Cohort under section 3621(14) of the Energy
Employees Occupational Illness Compensation Program Act of 2000, (42 U.S.C. 7384I(14))
7. Other [fill in blank]
Mustard Gas and/or Lewisite
1. Field or chamber testing
2. Battlefield conditions in World War I (WWI)
3. Present at the German air raid on the harbor of Bari, Italy, in World War II (WWII)
4. Handled, manufactured, or transported vesicant (blistering) agents during military service
5. Other [fill in blank]
Risk Factors Associated with Hepatitis C
1. Organ transplant prior to 1992
2. Transfusion of blood or blood products before 1992
3. Hemodialysis
4. Accidental exposure to blood by healthcare workers (to include combat medic or corpsman)
5. Intravenous drug use or intranasal cocaine use
6. High risk sexual activity
7. Other direct percutaneous (through the skin) exposure to blood such as by tattooing, body piercing, acupuncture
with non-sterile needles, and shared toothbrushes or shaving razors
8. Other [fill in blank]
Water Contamination at Camp Lejeune
1. Camp Lejeune (On base)
2. Camp Lejeune (Off base)
3. Other [fill in blank]
Item 7A - Please identify the start date(s) of your exposure
Item 7B - Please identify the end date(s) of your exposure

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Section IV (Prior/Post Military Occupational Information):
Item 8A - Please identify your occupation(s) prior to military service
Item 8B - Please identify your occupation(s) post military service
Section V (Prior/Post Military Exposure):
Item 9 - Please identify any exposure(s) prior to or post military service that may have resulted in the onset of your
claimed condition due to military service exposure.
Section VI (Individual Exposure Particulars): Herbicides (i.e. Agent Orange) Exposure
Item 10 - If you were exposed to herbicides at the Korean Demilitarized Zone, identify your military unit assignment from
August 1968 to August 1971. VA has identified a list of military units that were present at the Korean Demilitarized Zone
from August 1968 to August 1971, which is included in the below table.
1st Battalion, 38th Infantry
2nd Battalion, 38th Infantry
1st Battalion, 23rd Infantry
2nd Battalion, 23rd Infantry
2nd Military Police Company,
2nd Infantry Division

3rd Battalion, 23rd Infantry
2nd Battalion, 31st Infantry
3rd Battalion, 32nd Infantry
1st Battalion, 9th Infantry
4th Squadron, 7th Cavalry,
Counter Agent Company

2nd Battalion, 9th Infantry
1st Battalion, 72nd Armor
2nd Battalion, 72nd Armor
1st Battalion, 12th Artillery
2nd Squadron, 10th Cavalry

13th Engineer Combat Battalion 1st Battalion, 17th Infantry
1st Battalion, 73rd Armor
1st Battalion, 31st Infanty
1st Battalion, 32nd Infantry
Crew of the USS Pueblo

2nd Battalion, 17th Infantry
2nd Battalion, 31st Infantry
2nd Battalion, 32nd Infantry

1st Battalion, 15th Artillery
7th Battalion, 17th Artillery
5th Battalion, 38, Artillery
6th Battalion, 37th Artillery
United Nations Command
Security Battalion-Joint Security
Area (UNCSB-JSA)
Other (fill in blank)

Item 11A- If you were exposed to herbicides in Vietnam, identify where were you exposed
Item 11B- If you were exposed to herbicides in Vietnam via brown water (inland waterways of Vietnam) or blue water
(offshore waters of Vietnam), please list the name of your naval vessel
Item 12A- If you were exposed to herbicides in Thailand, identify at which Royal Thai Air Force base you were exposed.
VA has identified several locations where exposure to herbicides in Thailand could have occurred. Please review the
table below and identify your military location assignment. If other, please state where.
Royal Thai Air Force at U-Tapao Royal Thai Air Force at Nakhon Royal Thai Air Force at Takhli
Phanom
Royal Thai Air Force at Ubon
Royal Thai Air Force at Udorn
Royal Thai Air Force at Korat

Royal Thai Air Force at Don
Muang
Other [fill in blank]

Item 12B - If you were exposed to herbicides in Thailand, identify your military job duty or assignment at the time. VA
has identified several military job duties that may have led to herbicide exposure in Thailand. Please review the table list
below and identify your military location or assignment at the time. If other, please state what your military job duty or
assignment was at the time.
Security Policeman
Security patrol dog handler

VA FORM 21-0964, FEB 2014

Member of the security police squadron
Job duty/assignment otherwise on the air
base perimeter as shown by evidence of
daily work duties, performance evaluation
reports, or other credible evidence.

Other [fill in blank]

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Section VI (Individual Exposure Particulars) Continued: Ionizing Radiation
Item 13A- If you were exposed to ionizing radiation due to assignment to a gaseous diffusion plant, please identify the
plant. VA has identified a list of gaseous fusion plants where exposure to ionizing radiation occurred. Please review the
table list below and identify which gaseous fusion plant you were exposed at during your military service. If other, please
state where.
Paducah, Kentucky

Portsmouth, Ohio

Area K25 at Oakridge,
Tennessee

Other [fill in blank]

Item 13B- Please select yes or no, based on whether your assignment at a gaseous diffusion plant was more than 250
days.
Item 14- If you were exposed to ionizing radiation due to atmospheric nuclear weapons testing, please identify which
operation you participated in. VA has identified a list of atmospheric nuclear weapons testing. Please review the table list
below and identify the atmospheric nuclear weapons test in which you participated during your military service. If other,
please identify.
Operation TRINITY (July 16,
1945, through August 6, 1945)

Operation BUSTER-JANGLE
(October 22, 1951, through
December 20, 1951)

Operation TEAPOT
(February 18, 1955, through
June 10, 1955)

Operation CROSSROADS
(July 1, 1946, through
August 31, 1946)

Operation TIMBLER-SNAPPER Operation WIGWAM (May 14,
(April 1, 1952, through June 20, 1955, through May 15, 1955)
1952)

Operation ARGUS (August 27,
1958, through September 10,
1958)
Operation HARDTACK II
(September 19, 1958, through
October 31, 1958)

Operation SANDSTONE
Operation IVY (November 1,
(April 15 1948, through May 20, 1952, through December 31,
1948)
1952)

Operation REDWING (May 5,
1956, through August 6, 1956)

Operation DOMINIC I (April 25,
1962, through December 31,
1962)

Operation RANGER
(January 27, 1951, through
February 6, 1951)

Operation PLUMBBOB (May
28, 1957, through October 22,
1957)

Operation DOMINIC II/
PLOWSHARE (July 6, 1962,
through August 15, 1962)

Operation UPSHOTKNOTHOLE (March 17, 1953,
through June 20, 1953)

Operation GREENHOUSE
Operation CASTLE (March 1,
(April 8, 1951, through June 20, 1954, through May 31, 1954)
1951)

Other [fill in blank]
Operation HARDTACK I
(April 28, 1958, through October
31, 1958)

Item 15 - If you are claiming cancer in relation to ionizing radiation, please select yes or no based on whether a family
member has ever been diagnosed with cancer or leukemia. If you select "yes," respond to the follow-up questions.
Item 16 - Please select yes or no based on whether you have ever been exposed to other known carcinogens,
including smoking. If you select "yes," to Item 16, answer the below follow-up questions asking you to explain your
type of exposure. If you smoke, indicate how many packs per day you smoke and how many years you have smoked.
Item 17 - Please identify the following items, if you are claiming skin cancer in association with ionizing radiation
A. What type of skin cancer do you have (i.e. basal cell, sqamous cell, or melonoma)?
B. What is the specific site of each lesion?
C. What is the extent of your exposure in the sun?
D. What is the date your skin cancer was first diagnosed or treated?
Item 18 - Please identify any additional information you wish to include to support your claim. (Example: multiple
periods of exposure or explain an "other" selection that has not already been identified by the VA.)

VA FORM 21-0964, FEB 2014

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OMB No. 2900-XXXX
Respondent Burden: 20 minutes
Expiration Date: XXXX

STATEMENT IN SUPPORT FOR DISABILITY AND RELATED
COMPENSATION BENEFITS DUE TO EXPOSURE
IMPORTANT: This form is intended to be completed with VA Form 21-526,
Veterans Application for Compensation and/or Pension, or VA Form 21-526EZ,
Application for Disability Compensation and Related Compensation Benefits.
NOTE: Service connection may be granted for a disability related to exposure
during military service if evidence demonstrates that the veteran was exposed in
service and the exposure resulted in a disease usually associated with such exposure.
Exposure, in itself, is not a disability.

VA DATE STAMP
(Do Not Write In This Space)

SECTION I - IDENTIFICATION AND CLAIM INFORMATION
1. NAME OF VETERAN/SERVICE MEMBER (Last, First, Middle)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER (If applicable)

SECTION II - EXPOSURE TYPE
4. TYPE OF EXPOSURE (Complete a separate VA Form 21-0964, Statement in Support for Disability Compensation Related Compensation Benefits
Due to Exposure, for each type of exposure claimed.)
Asbestos
Cold Weather
Gulf Wars and Other Geographical Locations Environmental Hazard
Herbicides (i.e., Agent Orange) (Please complete Section VI, Individual Exposure Particulars, Questions 10-12)
Ionizing Radiation (Please complete Section VI, Individual Exposure Particulars, Questions 13-17)
Mustard Gas and/or Lewisite
Risk factors associated with Hepatitis C
Water Contamination at Camp Lejeune

SECTION III - EXPOSURE DATE(S) AND LOCATION(S)
5. LOCATION(S) OF EXPOSURE (City/Town, State, Country)
6. HOW WERE YOU EXPOSED?

Other (fill in blank): _______________________________________________________________________________________________________________
7A. START DATE(S) OF EXPOSURE

7B. END DATE(S) OF EXPOSURE

SECTION IV - PRIOR/POST MILITARY OCCUPATIONAL INFORMATION
8A. LIST OCCUPATION(S) PRIOR TO MILITARY SERVICE
Other (fill in blank): _______________________________________________________________________________________________________________
8B. LIST OCCUPATION(S) POST MILITARY SERVICE
Other (fill in blank): _______________________________________________________________________________________________________________

SECTION V - PRIOR/POST MILITARY EXPOSURE
9. LIST OTHER FORMS OF EXPOSURE THAT YOU WERE EXPOSED TO PRIOR AND POST MILITARY SERVICE THAT COULD BE
ATTRIBUTED TO YOUR CLAIM CONDITION.

SECTION VI - INDIVIDUAL EXPOSURE PARTICULARS
Herbicides (i.e., Agent Orange) Exposure

10. IF YOU WERE EXPOSED TO HERBICIDES AT THE KOREAN DEMILITARIZED ZONE, WHAT WAS YOUR MILITARY UNIT ASSIGNMENT
FROM APRIL 1968 TO AUGUST 1971?

Other (fill in blank): _______________________________________________________________________________________________________________
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11A. IF YOU WERE EXPOSED TO HERBICIDES IN VIETNAM, WHERE
WERE YOU EXPOSED?
Set foot on land

11B. IF YOU WERE EXPOSED TO HERBICIDES IN VIETNAM VIA
BROWN WATER (inland waterways of Vietnam) OR BLUE WATER
(offshore waters of Vietnam), PLEASE LIST THE NAME OF YOUR
NAVAL VESSEL.

Brown water (inland waterways of Vietnam)
Blue water (offshore waters of Vietnam)
Other _____________________________________________________
12A. IF YOU WERE EXPOSED TO HERBICIDES IN THAILAND, AT
WHICH ROYAL THAI AIR FORCE BASE WERE YOU EXPOSED?
Other (fill in blank): ________________________________________________

Other (fill in blank): ______________________________________________
12B. IF YOU WERE EXPOSED TO HERBICIDES IN THAILAND,
WHAT WAS YOUR MILITARY JOB DUTY OR ASSIGNMENT AT THE
TIME?
Other (fill in blank): ______________________________________________

SECTION VI - INDIVIDUAL EXPOSURE PARTICULARS (Continued)
Ionizing Radiation Exposure

13A. IF YOU WERE EXPOSED TO IONIZING RADIATION DUE TO
ASSIGNMENT TO A GASEOUS DIFFUSION PLANT, AT WHICH PLANT
WERE YOU EXPOSED?
Other (fill in blank): _______________________________________________

13B. IF YOU WERE EXPOSED TO IONIZING RADIATION DUE TO
ASSIGNMENT TO A GASEOUS DIFFUSION PLANT, WAS THE
ASSIGNMENT MORE THAN 250 DAYS?
YES

NO

14. IF YOU WERE EXPOSED TO IONIZING RADIATION DUE TO ATMOSPHERIC NUCLEAR WEAPONS TESTING, WHICH OPERATION DID
YOU PARTICIPATE IN?
Other (fill in blank): _________________________________________________________________________________________________________________
15. IF YOU ARE CLAIMING CANCER IN RELATION TO IONIZING
RADIATION, HAS A FAMILY MEMBER EVER BEEN DIAGNOSED WITH
CANCER OR LEUKEMIA?
YES

NO

If "Yes," which family member? _____________________________________
What is the diagnosed condition? ____________________________________

16. HAVE YOU EVER BEEN EXPOSED TO OTHER KNOWN
CARCINOGENS, INCLUDING SMOKING?
YES

NO

If "Yes," what? ______________________________________________
How many packs per day did you smoke? ________
How many years did you smoke? ____________________

17. IF YOU ARE CLAIMING SKIN CANCER IN ASSOCIATION WITH IONIZING RADIATION:
17A. WHAT TYPE OF SKIN CANCER IS IT?
17B. WHAT IS THE SPECIFIC SITE OF EACH LESION?

Other (fill in blank): _______________________________________________
17C. WHAT IS THE EXTENT OF YOUR EXPOSURE TO THE SUN?

17D. WHAT IS THE DATE YOUR SKIN CANCER WAS FIRST
DIAGNOSED OR TREATED?

Other (fill in blank): _______________________________________________

SECTION VII - ADDITIONAL INFORMATION

PRIVACY ACT INFORMATION: The 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, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your
obligation to respond is voluntary; however, no allowance of compensation or pension may be granted unless this form is completed fully as required by law. Giving
us you and your dependents' Social Security numbers is mandatory. Applicants are required to provide their SSN and the SSN of any dependents for whom benefits
are claimed under Title 38 USC 5101 (c)(1). The 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. Information submitted is subject to verification through computer matching programs with other Federal or state agencies. Income
and employment information furnished by you will be compared with information obtained by VA from the Secretary of Health and Human Services or the
Secretary of the Treasury under clause (viii) of section 6103(1)(7)(D) of the Internal Revenue Code of 1986.
RESPONDENT BURDEN: We need this information to determine your eligibility for compensation and/or pension (38 U.S.C. 5101). Title 38, United States Code,
allows us to ask for this information. We estimate that you will need an average of 20 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 21-0964, FEB 2014

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