VA Form 21-0960I-3 Infectious Diseases (Other than HIV-Related Illness, Chr

OMB Approved No. 2900-0781
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

INFECTIOUS DISEASES (OTHER THAN HIV-RELATED ILLNESS, CHRONIC FATIGUE
SYNDROME, OR TUBERCULOSIS) 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 BEFORE
COMPLETING THIS 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. VA reserves the right to confirm the authenticity of ALL DBQs completed by
private health care providers.
NOTE - If the veteran has HIV-related illness, complete VA Form 21-0960I-2, if chronic fatigue syndrome complete VA Form 21-0960Q-1, or if tuberculosis complete
VA Form 21-0960I-6 in lieu of this questionnaire.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN INFECTIOUS DISEASE? (This is the condition the veteran is claiming

or for which an exam has been requested)

NO (If "Yes," complete Item 1B)

YES

NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different
from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the "Remarks"
section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an appropriate date determined through record review or
reported history.
1B. SELECT THE VETERAN'S CONDITION (Check all that apply):
MALARIA

ICD code:

Date of diagnosis:

ASIATIC CHOLERA

ICD code:

Date of diagnosis:

VISCERAL LEISHMANIASIS

ICD code:

Date of diagnosis:

LEPROSY (Hansen's disease)

ICD code:

Date of diagnosis:

LYMPHATIC FILARIASIS

ICD code:

Date of diagnosis:

BARTONELLOSIS

ICD code:

Date of diagnosis:

PLAGUE

ICD code:

Date of diagnosis:

RELAPSING FEVER

ICD code:

Date of diagnosis:

RHEUMATIC FEVER

ICD code:

Date of diagnosis:

ENDOCARDITIS

ICD code:

Date of diagnosis:

SYPHILIS

ICD code:

Date of diagnosis:

BRUCELLOSIS

ICD code:

Date of diagnosis:

TYPHUS SCRUB

ICD code:

Date of diagnosis:

MELIOIDOSIS

ICD code:

Date of diagnosis:

LYME DISEASE

ICD code:

Date of diagnosis:

PARASITIC DISEASE, NOS

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

OTHER (specify):
OTHER DIAGNOSIS #1:
OTHER DIAGNOSIS #2:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO INFECTIOUS DISEASES, LIST USING ABOVE FORMAT:

NOTE - The diagnosis of malaria depends on the identification of the malarial parasites in blood smears. If the veteran served in an endemic area and presents signs and
symptoms compatible with malaria, the diagnosis may be based on clinical grounds alone. Relapses must be confirmed by the presence of malarial parasites in blood
smears.
SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:
C-FILE (VA ONLY)
OTHER, DESCRIBE:

SECTION III - MEDICAL HISTORY
3A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S INFECTIOUS DISEASE CONDITION(S) (brief summary):

3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S INFECTIOUS DISEASE CONDITION(S))?
YES

VA FORM
XXX XXXX

NO

(If "Yes," list only those medications required for the veteran's infectious disease condition(s))

21-0960I-3

SUPERSEDES VA FORM 21-0960I-3, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION IV -STATUS, SYMPTOMS AND RESIDUALS
4A. COMPLETE THE FOLLOWING SECTION(S) FOR EACH OF THE VETERAN'S INFECTIOUS DISEASE CONDITION(S):
Disease #1:
A. Status of disease:

Active

Inactive

If "Inactive," date condition became inactive:
B. Does the veteran have symptoms attributable to disease #1?
Yes

No

If "Yes," describe:
C. Does the veteran have residuals attributable to disease #1?
Yes
No
If "Yes," describe:

NOTE: If the veteran has symptoms or residuals, ALSO complete the appropriate questionnaire for each symptomatic or residual condition
(such as Skin, Heart, Peripheral or Central Nervous System, Respiratory and appropriate Joint and Gastrointestinal Questionnaire)
Disease #2:
A. Status of disease:

Active

Inactive

If "Inactive," date condition became inactive:
B. Does the veteran have symptoms attributable to disease #2?
Yes

No

If "Yes," describe:
C. Does the veteran have residuals attributable to disease #2?
Yes

No

If "Yes," describe:

NOTE: If the veteran has symptoms or residuals, ALSO complete the appropriate questionnaire for each symptomatic or residual condition
(such as Skin, Heart, Peripheral or Central Nervous System, Respiratory and appropriate Joint and Gastrointestinal Questionnaire)
Disease #3:
A. Status of disease:

Active

Inactive

If "Inactive," date condition became inactive:
B. Does the veteran have symptoms attributable to disease #3?
Yes

No

If "Yes," describe:
C. Does the veteran have residuals attributable to disease #3?
Yes

No

If "Yes," describe:

NOTE: If the veteran has symptoms or residuals, ALSO complete the appropriate questionnaire for each symptomatic or residual condition
(such as Skin, Heart, Peripheral or Central Nervous System, Respiratory and appropriate Joint and Gastrointestinal Questionnaire)
4B. IF THE VETERAN HAS ANY ADDITIONAL INFECTIOUS DISEASE CONDITIONS, LIST AND DESCRIBE BY USING THE FORMAT SHOWN IN ITEM 4A

SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
5A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THE
DIAGNOSIS SECTION?
YES

NO

IF "YES," ARE ANY OF THESE SCARS PAINFUL AND/OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM
6 square inches); OR ARE LOCATED ON THE HEAD, FACE, OR NECK?
YES

NO

IF "YES," ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE (DBQ).
IF "NO," PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS.
LOCATION:__________________________________

MEASUREMENTS: Length_____________ cm X width _____________ cm.

NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars, enter
additional locations and measurements in the "Remarks" section. It is not necessary to also complete a Scars/Disfigurement DBQ.
5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES

NO

(If "Yes," describe (brief summary):

VA FORM 21-0960I-3, XXX XXXX

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SECTION VI - DIAGNOSTIC TESTING
NOTE - If testing has been performed and reflects veteran's current condition, repeat testing is not required.
6. ARE THERE ANY SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

(If "Yes," provide type of test or procedure, date and results (brief summary):

SECTION VII - FUNCTIONAL IMPACT
7. DOES THE VETERAN'S INFECTIOUS DISEASE CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of each of the veteran's infectious disease condition(s), providing one or more examples):

SECTION VIII - REMARKS
8. REMARKS (If any):

SECTION IX - 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 AND FAX NUMBERS

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.benefits.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 voluntary. 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 21-0960I-3, XXX XXXX

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