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pdfOMB Approved No. 2900-0776
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX
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
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 ONE OR MORE SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK?
YES
NO
(If "Yes," complete Item 1B)
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK:
DIAGNOSIS # 1:
ICD CODE:
DATE OF DIAGNOSIS:
DIAGNOSIS # 2:
ICD CODE:
DATE OF DIAGNOSIS:
DIAGNOSIS # 3:
ICD CODE:
DATE OF DIAGNOSIS:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK DUE
TO SCARS OR OTHER CAUSES, 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 - SCARS OF THE TRUNK AND EXTREMITIES
2. DOES THE VETERAN HAVE ANY SCARS ON THE TRUNK OR EXTREMITIES (REGIONS OTHER THAN THE HEAD, FACE OR NECK)?
YES
NO
(If "Yes," complete this section)
(If "No," skip to Section III)
2-1 - MEDICAL HISTORY
A. DESCRIBE THE HISTORY (including cause/origin and course) OF THE VETERAN'S SCAR(S) OF THE TRUNK OR EXTREMITIES (brief summary):
B. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES PAINFUL?
YES
NO
If yes, specify the number of painful scars:
1
2
3
4
5 or more
DESCRIBE THE PAIN (if there are multiple painful scars, be sure to adequately identify which scars are painful):
C. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES UNSTABLE, WITH FREQUENT LOSS OF COVERING OF SKIN OVER THE SCAR?
YES
NO
If yes, specify the number of unstable scars:
1
2
3
4
5 or more
DESCRIBE THE LOSS OF COVERING OF SKIN OVER THE SCAR (if there are multiple unstable scars, be sure to adequately identify which scars are unstable):
D. ARE ANY OF THE SCARS BOTH PAINFUL AND UNSTABLE?
YES
NO
If yes, specify number of scars that are both painful and unstable:
1
2
3
4
5 or more
DESCRIBE THE LOCATION OF THESE SCARS:
VA FORM
MAR 2014
21-0960F-1
SUPERSEDES VA FORM 21-0960F-1, OCT 2012,
WHICH WILL NOT BE USED
Page 1
SECTION II - SCARS OF THE TRUNK AND EXTREMITIES (Continued)
E. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES DUE TO BURNS?
YES
NO
If yes, identify each burn scar and state depth of original burn:
Burn scar #1:
Full thickness or sub-dermal
Deep partial thickness
Less than deep partial thickness
Full thickness or sub-dermal
Deep partial thickness
Less than deep partial thickness
Burn scar #2:
F. IF THERE ARE ADDITIONAL BURN SCARS OF THE TRUNK AND EXTREMITIES, LIST USING THE SAME FORMAT:
2-2 - PHYSICAL EXAM FOR SCARS ON THE TRUNK AND EXTREMITIES
DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES
INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:
A. RIGHT UPPER EXTREMITY
Affected
Not affected
Specify location of scars on right upper extremity and number them:
Indicate types of scars and provide measurements (check all that apply):
Linear
Length of each linear scar:
Scar # 1:
cm
Scar # 2:
cm
Scar # 3:
Scar # 4:
cm
Scar # 5:
cm
If additional scars, list using same format:
cm
Superficial non-linear
Length and width of each superficial non-linear scar:
x
cm
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:
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 and number them:
Indicate types of scars and provide measurements (check all that apply):
Linear
Length of each linear scar:
Scar # 1:
cm
Scar # 2:
cm
Scar # 3:
Scar # 4:
cm
Scar # 5:
cm
If additional scars, list using same format:
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
C. RIGHT LOWER EXTREMITY
Affected
Not affected
Specify location of scars on right lower extremity and number them:
Indicate types of scars and provide measurements (check all that apply):
Linear
Length of each linear scar:
Scar # 1:
cm
Scar # 2:
cm
Scar # 3:
Scar # 4:
cm
Scar # 5:
cm
If additional scars, list using same format:
VA FORM 21-0960F-1, MAR 2014
cm
Page 2
SECTION II - SCARS OF THE TRUNK AND EXTREMITIES (Continued)
DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES (Continued)
INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:
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 and number them:
Indicate types of scars and provide measurements (check all that apply):
Linear
Length of each linear scar:
Scar # 1:
cm
Scar # 2:
cm
Scar # 3:
Scar # 4:
cm
Scar # 5:
cm
If additional scars, list using same format:
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 and number them:
Indicate types of scars and provide measurements (check all that apply):
Linear
Length of each linear scar:
Scar # 1:
cm
Scar # 2:
cm
Scar # 3:
Scar # 4:
cm
Scar # 5:
cm
If additional scars, list using same format:
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
F. POSTERIOR TRUNK
Affected
Not affected
Specify location of scars on posterior trunk and number them:
Indicate types of scars and provide measurements (check all that apply):
Linear
Length of each linear scar:
Scar # 1:
cm
Scar # 2:
cm
Scar # 3:
Scar # 4:
cm
Scar # 5:
cm
If additional scars, list using same format:
cm
Superficial non-linear
Length and width of each superficial non-linear scar:
x
cm
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, MAR 2014
Page 3
SECTION II - SCARS OF THE TRUNK AND EXTREMITIES (Continued)
DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES (Continued)
INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:
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
SUMMARY OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES
A. 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
B. 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
SECTION III - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK
3. DOES THE VETERAN HAVE ANY SCARS OR DISFIGUREMENT OF HEAD, FACE OR NECK?
YES
NO
(If "Yes," complete this section) (If "No," skip to Section IV)
3-1 - MEDICAL HISTORY
A. DESCRIBE THE HISTORY (including cause/origin and course) OF THE VETERAN'S SCAR(S) OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK
(brief summary):
B. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK PAINFUL?
YES
NO
If yes, specify the number of painful scars:
1
2
3
4
5 or more
DESCRIBE THE PAIN (if there are multiple painful scars, be sure to adequately identify which scars are painful):
C. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK UNSTABLE, WITH FREQUENT LOSS OF COVERING OF SKIN OVER THE SCAR?
YES
NO
If yes, specify the number of unstable scars:
1
2
3
4
5 or more
DESCRIBE THE LOSS OF COVERING OF SKIN OVER THE SCAR (if there are multiple unstable scars, be sure to adequately identify which scars are unstable):
D. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK BOTH PAINFUL AND UNSTABLE?
YES
NO
If yes, specify number of scars that are both painful and unstable:
1
2
3
4
5 or more
DESCRIBE THE LOCATION OF THESE SCARS:
E. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK DUE TO BURNS?
YES
NO
If yes, identify each burn scar and state depth of original burn:
Burn scar #1:
Full thickness or sub-dermal
Deep partial thickness
Less than deep partial thickness
Full thickness or sub-dermal
Deep partial thickness
Less than deep partial thickness
Burn scar #2:
VA FORM 21-0960F-1, MAR 2014
Page 4
SECTION III - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK (Continued)
3-1 - MEDICAL HISTORY (Continued)
F. IF THERE ARE ADDITIONAL BURN SCARS OF THE HEAD, FACE OR NECK, LIST USING THE SAME FORMAT:
3-2 - PHYSICAL EXAM FOR SCARS OR DISFIGUREMENT OF THE HEAD, FACE AND NECK
DETAILS OF SCAR OR DISFIGUREMENT FOR THE HEAD, FACE AND NECK
A. IDENTIFY EACH SCAR OR DISFIGUREMENT AND PROVIDE MEASUREMENTS:
Scar/Disfigurement #1
Indicate type of impairment:
Scar
Disfigurement
Location of scar/disfigurement #1:
Length and width (at widest part) of scar/disfigurement #1:
x
cm
x
cm
x
cm
x
cm
x
cm
Scar/Disfigurement #2
Indicate type of impairment:
Scar
Disfigurement
Location of scar/disfigurement #2:
Length and width (at widest part) of scar/disfigurement #2:
Scar/Disfigurement #3
Indicate type of impairment:
Scar
Disfigurement
Location of scar/disfigurement #3:
Length and width (at widest part) of scar/disfigurement #3:
Scar/Disfigurement #4
Indicate type of impairment:
Scar
Disfigurement
Location of scar/disfigurement #4:
Length and width (at widest part) of scar/disfigurement #4:
Scar/Disfigurement #5
Indicate type of impairment:
Scar
Disfigurement
Location of scar/disfigurement #5:
Length and width (at widest part) of scar/disfigurement #5:
If additional scars or disfigurement, list using the same format:
B. IS THERE ELEVATION, DEPRESSION, ADHERENCE TO UNDERLYING TISSUE, OR MISSING UNDERLYING SOFT TISSUE?
YES
NO
(If yes, check all that apply):
Surface contour elevated on palpation
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1
Scar/Disfigurement #2
Scar/Disfigurement #3
Scar/Disfigurement #4
Scar/Disfigurement #5
Other
Surface contour depressed on palpation
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1
Scar/Disfigurement #2
Scar/Disfigurement #3
Scar/Disfigurement #4
Scar/Disfigurement #5
Other
Scar adherent to underlying tissue
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1
Scar/Disfigurement #2
Scar/Disfigurement #3
Scar/Disfigurement #4
Scar/Disfigurement #5
Other
Underlying soft tissue missing
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1
Scar/Disfigurement #2
Scar/Disfigurement #3
Scar/Disfigurement #4
Scar/Disfigurement #5
Other
VA FORM 21-0960F-1, MAR 2014
Page 5
SECTION III - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK (Continued)
DETAILS OF SCAR OR DISFIGUREMENT FOR THE HEAD, FACE AND NECK (Continued)
C. IS THERE ABNORMAL PIGMENTATION OR TEXTURE OF THE HEAD, FACE, OR NECK?
YES
NO
(If yes, check all that apply):
Hypopigmentation
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1
Scar/Disfigurement #2
Scar/Disfigurement #3
Scar/Disfigurement #4
Scar/Disfigurement #5
Other
Hyperpigmentation
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1
Scar/Disfigurement #2
Scar/Disfigurement #3
Scar/Disfigurement #4
Scar/Disfigurement #5
Other
Induration and inflexibility
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1
Scar/Disfigurement #2
Scar/Disfigurement #3
Scar/Disfigurement #4
Scar/Disfigurement #5
Other
Abnormal texture
If checked, identify each affected scar/disfigurement:
Scar/Disfigurement #1
Scar/Disfigurement #2
Scar/Disfigurement #3
Scar/Disfigurement #4
Scar/Disfigurement #5
Other
Describe type of abnormal texture (for example, irregular, atrophic, shiny or scaly):
SUMMARY OF SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE AND NECK
A. PROVIDE APPROXIMATE COMBINED TOTAL AREA IN CENTIMETERS SQUARED FOR EACH CHARACTERISTIC OF DISFIGUREMENT:
1. Approximate total area of head, face and neck with hypo- or hyperpigmented areas:
cm2
2. Approximate total area of head, face and neck with abnormal texture:
cm2
3. Approximate total area of head, face and neck with missing underlying soft tissue:
cm2
4. Approximate total area of head, face and neck that is indurated and inflexible:
cm2
DISTORTION OF FACIAL FEATURES AND TISSUE LOSS FOR THE HEAD, FACE AND NECK
A. IS THERE GROSS DISTORTION OR ASYMMETRY OF FACIAL FEATURES OR VISIBLE OR PALPABLE TISSUE LOSS?
YES
NO
If yes, indicate features affected (check all that apply):
Nose
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):
For all checked features, provide brief description of the tissue loss, gross distortion and/or asymmetry of facial features:
VA FORM 21-0960F-1, MAR 2014
Page 6
SECTION IV - MISCELLANEOUS
NOTE: Complete this section for all scars or disfigurements, regardless of location.
LIMITATION OF FUNCTION/OTHER CONDITIONS
4A. DO ANY OF THE SCARS (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK RESULT IN LIMITATION OF FUNCTION?
YES
NO
IF YES, INDICATE WHICH SCARS (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK ARE CAUSING THE LIMITATION AND DESCRIBE
THE SPECIFIC LIMITATIONS:
4B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (such as muscle or
nerve damage) ASSOCIATED WITH ANY SCAR (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK?
YES
NO
IF YES, DESCRIBE (brief summary):
COLOR PHOTOGRAPHS
4C. PROVIDE COLOR PHOTOGRAPHS FOR ANY SCAR(S) OR DISFIGURING CONDITIONS OF THE HEAD, FACE AND/OR NECK.
Photographs not indicated
Photographs provided
Photographs not available
SECTION V - FUNCTIONAL IMPACT
5. DOES THE VETERAN'S SCAR(S) (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
IF YES, DESCRIBE IMPACT OF THE VETERAN'S SCAR(S) (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK, PROVIDING ONE OR
MORE EXAMPLES
SECTION VI - REMARKS
6. REMARKS (if any):
SECTION VII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
7A. PHYSICIAN'S SIGNATURE
7D. PHYSICIAN'S PHONE NUMBER
7B. PHYSICIAN'S PRINTED NAME
7E. PHYSICIAN'S MEDICAL LICENSE NUMBER
7C. DATE SIGNED
7F. PHYSICIAN'S ADDRESS
NOTE: VA may obtain additional medical information, including an examination, 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 30 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
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VA FORM 21-0960F-1, MAR 2014
Page 7
| File Type | application/pdf |
| File Modified | 2014-03-26 |
| File Created | 2011-12-20 |