VA Form 21-0960C-2 Amotrophic Lateral Sclerosis (Lou Gehrig's Disease) Disa

OMB Control No. 2900-0779
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/XXX

AMYOTROPHIC LATERAL SCLEROSIS (LOU GEHRIG'S DISEASE)
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. VA reserves the right to confirm the authenticity of ALL DBQs completed by
private health care providers.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AMYOTROPHIC LATERAL SCLEROSIS (ALS)?
YES

NO

(If "Yes," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO AMYOTROPHIC LATERAL SCLEROSIS (ALS):
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 AMYOTROPHIC LATERAL SCLEROSIS, LIST USING ABOVE FORMAT:

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

2B. DOMINANT HAND
RIGHT

LEFT

AMBIDEXTROUS

SECTION III - CONDITIONS, SIGNS AND SYMPTOMS DUE TO ALS
3A. DOES THE VETERAN HAVE ANY MUSCLE WEAKNESS IN THE UPPER AND/OR LOWER EXTREMITIES ATTRIBUTABLE TO ALS?
YES

NO

(If "Yes," report under strength testing in Section IV, Neurologic Exam)
3B. DOES THE VETERAN HAVE ANY PHARYNX AND/OR LARYNX AND/OR SWALLOWING CONDITIONS ATTRIBUTABLE TO ALS?
YES

NO

(If "Yes," check all that apply)
CONSTANT INABILITY TO COMMUNICATE BY SPEECH
SPEECH NOT INTELLIGIBLE OR INDIVIDUAL IS APHONIC
PARALYSIS OF SOFT PALATE WITH SWALLOWING DIFFICULTY (nasal regurgitation) AND SPEECH IMPAIRMENT
HOARSENESS
MILD SWALLOWING DIFFICULTIES
MODERATE SWALLOWING DIFFICULTIES
SEVERE SWALLOWING DIFFICULTIES, PERMITTING PASSAGE OF LIQUIDS ONLY
REQUIRES FEEDING TUBE DUE TO SWALLOWING DIFFICULTIES
OTHER (describe):
3C. DOES THE VETERAN HAVE ANY RESPIRATORY CONDITIONS ATTRIBUTABLE TO ALS?
YES

NO

(If "Yes," provide PFT results in Section XIII, Diagnostic Testing)
VA FORM
XXX XXXX

21-0960C-2

SUPERSEDES VA FORM 21-0960C-2, FEB 2015,
WHICH WILL NOT BE USED.

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION III - CONDITIONS, SIGNS AND SYMPTOMS DUE TO ALS (Continued)
3D. DOES THE VETERAN HAVE SIGNS AND/OR SYMPTOMS OF SLEEP APNEA OR SLEEP APNEA-LIKE CONDITION ATTRIBUTABLE TO ALS?

NOTE: If signs and/or symptoms of sleep apnea or sleep apnea-like condition are due to ALS, these symptoms are due to weakness in the palatal, pharyngeal, laryngeal,
and/or respiratory musculature. A sleep study is not indicated to report symptoms of sleep apnea or sleep apnea-like conditions that are attributable to ALS.
YES

NO

(If "Yes," check all that apply)
PERSISTENT DAYTIME HYPERSOMNOLENCE
REQUIRES USE OF BREATHING ASSISTANCE DEVICE SUCH AS CONTINUOUS AIRWAY PRESSURE (CPAP) MACHINE
CHRONIC RESPIRATORY FAILURE WITH CARBON DIOXIDE RETENTION OR COR PULMONALE
REQUIRES TRACHEOSTOMY
3E. DOES THE VETERAN HAVE ANY BOWEL IMPAIRMENT ATTRIBUTABLE TO ALS?
YES

NO

(If "Yes," check all that apply)
SLIGHT IMPAIRMENT OF SPHINCTER CONTROL, WITHOUT LEAKAGE
CONSTANT SLIGHT IMPAIRMENT OF SPHINCTER CONTROL, OR OCCASIONAL MODERATE LEAKAGE
OCCASIONAL INVOLUNTARY BOWEL MOVEMENTS, NECESSITATING WEARING OF A PAD
EXTENSIVE LEAKAGE AND FAIRLY FREQUENT INVOLUNTARY BOWEL MOVEMENTS
TOTAL LOSS OF BOWEL SPHINCTER CONTROL
CHRONIC CONSTIPATION
OTHER BOWEL IMPAIRMENT (describe):
3F. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING URINE LEAKAGE ATTRIBUTABLE TO ALS?
YES

NO

(If "Yes," check all that apply)
DOES NOT REQUIRE/DOES NOT USE ABSORBENT MATERIAL
REQUIRES ABSORBENT MATERIAL THAT IS CHANGED LESS THAN 2 TIMES PER DAY
REQUIRES ABSORBENT MATERIAL THAT IS CHANGED 2 TO 4 TIMES PER DAY
REQUIRES ABSORBENT MATERIAL THAT IS CHANGED MORE THAN 4 TIMES PER DAY
3G. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING SIGNS AND/OR SYMPTOMS OF URINARY FREQUENCY ATTRIBUTABLE TO ALS?
YES

NO

(If "Yes," check all that apply)
DAYTIME VOIDING INTERVAL GREATER THAN 3 HOURS

NIGHTTIME AWAKENING TO VOID LESS THAN 2 TIMES

DAYTIME VOIDING INTERVAL BETWEEN 2 AND 3 HOURS

NIGHTTIME AWAKENING TO VOID 2 TIMES

DAYTIME VOIDING INTERVAL BETWEEN 1 AND 2 HOURS

NIGHTTIME AWAKENING TO VOID 3 TO 4 TIMES

DAYTIME VOIDING INTERVAL LESS THAN 1 HOUR

NIGHTTIME AWAKENING TO VOID 5 OR MORE TIMES

3H. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING FINDINGS, SIGNS AND/OR SYMPTOMS OF OBSTRUCTED VOIDING ATTRIBUTABLE TO ALS?
YES

NO

(If "Yes," check all signs and symptoms that apply)
HESITANCY

(If checked, is hesitancy marked?)
YES

NO

SLOW OR WEAK STREAM

(If checked, is stream markedly slow or weak?)
YES

NO

DECREASED FORCE OF STREAM

(If checked, is force of stream markedly decreased?)
YES

NO

STRICTURE DISEASE REQUIRING DILATATION 1 TO 2 TIMES PER YEAR
STRICTURE DISEASE REQUIRING PERIODIC DILATATION EVERY 2 TO 3 MONTHS
RECURRENT URINARY TRACT INFECTIONS SECONDARY TO OBSTRUCTION
UROFLOWMETRY PEAK FLOW RATE LESS THAN 10cc/sec
POST VOID RESIDUALS GREATER THAN 150 cc
URINARY RETENTION REQUIRING INTERMITTENT OR CONTINUOUS CATHETERIZATION
3I. DOES THE VETERAN HAVE VOIDING DYSFUNCTION REQUIRING THE USE OF AN APPLIANCE ATTRIBUTABLE TO ALS?
YES

NO

(If "Yes," describe appliance):

VA FORM 21-0960C-2, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION III - CONDITIONS, SIGNS AND SYMPTOMS DUE TO ALS (Continued)
3J. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT INFECTIONS ATTRIBUTABLE TO ALS?
YES

NO

(If "Yes," check all treatments that apply)
NO TREATMENT
LONG-TERM DRUG THERAPY

(If checked, list medications used for urinary tract infection and indicate dates for courses of treatment over the past 12 months)
HOSPITALIZATION

(If checked, indicate frequency of hospitalization)
1 or 2 per year
More than 2 per year
DRAINAGE

(If checked, indicate dates when drainage performed over past 12 months):
OTHER MANAGEMENT/TREATMENT NOT LISTED ABOVE (Description of management/treatment including dates of treatment):

3K. DOES THE VETERAN (if male) HAVE ERECTILE DYSFUNCTION?
YES

NO

(If "Yes," is the erectile dysfunction as likely as not (at least a 50% probability) attributable to ALS?)
YES

NO

(If "No," provide the etiology of the erectile dysfunction):
(If "Yes," is the veteran able to achieve an erection (without medication) sufficient for penetration and ejaculation?)
YES

NO

(If "No," is the veteran able to achieve an erection (with medication) sufficient for penetration and ejaculation?)
YES

NO

SECTION IV - NEUROLOGIC EXAM
4A. SPEECH
NORMAL

ABNORMAL

(If speech is abnormal, describe):
4B. GAIT
NORMAL

ABNORMAL (describe):

(If gait is abnormal and the veteran has more than one medical condition contributing to the abnormal gait, identify the condition(s) and describe each condition's
contribution to the abnormal gait):
4C. STRENGTH - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement

2/5 No movement against gravity

4/5 Less than normal strength

1/5 Visible muscle movement, but no joint movement

3/5 No movement against resistance

5/5 Normal strength

ALL NORMAL
Elbow Flexion:

RIGHT:

5/5

4/5

3/5

2/5

1/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

Wrist Extension:

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

Grip:

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

Elbow Extension:
Wrist Flexion:

Pinch:

(thumb to index finger)
Knee Flexion:
Knee Extension:

Ankle Plantar Flexion:
Ankle Dorsiflexion:

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5
5/5

4/5
4/5

3/5
3/5

2/5
2/5

1/5
1/5

0/5
0/5

RIGHT:
LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

VA FORM 21-0960C-2, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IV - NEUROLOGIC EXAM (Continued)
4D. DEEP TENDON REFLEXES (DTRs) - RATE REFLEXES ACCORDING TO THE FOLLOWING SCALE:
0 Absent

1+ Decreased

2+ Normal

3+ Increased without clonus

4+ Increased with clonus

ALL NORMAL
Biceps:
Triceps:
Brachioradialis:
Knee:
Ankle:

RIGHT:

0

1+

2+

3+

LEFT:

0

1+

2+

3+

4+
4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

4E. PLANTAR (Babinski) REFLEX
RIGHT:

Plantar flexion (normal, or negative Babinski)
Dorsiflexion (abnormal, or positive Babinski)

LEFT:

Plantar flexion (normal, or negative Babinski)
Dorsiflexion (abnormal, or positive Babinski)

4F. DOES THE VETERAN HAVE MUSCLE ATROPHY ATTRIBUTABLE TO ALS?
YES

NO

(If muscle atrophy is present, indicate location):

(When possible, provide difference measured in cm between normal and atrophied side, measured at maximum muscle bulk:

cm.)

4G. SUMMARY OF MUSCLE WEAKNESS IN THE UPPER AND/OR LOWER EXTREMITIES ATTRIBUTABLE TO ALS (check all that apply):
Right upper extremity muscle weakness:

None

Mild

Moderate

Severe

With atrophy

Complete (no remaining function)

Left upper extremity muscle weakness:

None

Mild

Moderate

Severe

With atrophy

Complete (no remaining function)

Right lower extremity muscle weakness:

None

Mild

Moderate

Severe

With atrophy

Complete (no remaining function)

Left lower extremity muscle weakness:

None

Mild

Moderate

Severe

With atrophy

Complete (no remaining function)

NOTE: If the Veteran has more than one medical condition contributing to the muscle weakness, identify the condition(s) and describe each condition's contribution to
the muscle weakness:

SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, 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 SECTION I, DIAGNOSIS?
YES

NO

(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than or equal to 39 square cm (6 square inches)?
Yes
No (If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ALS?
YES

NO

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

SECTION VI - MENTAL HEALTH MANIFESTATIONS DUE TO ALS OR ITS TREATMENT
6A. DOES THE VETERAN HAVE DEPRESSION, COGNITIVE IMPAIRMENT OR DEMENTIA, OR ANY OTHER MENTAL DISORDER ATTRIBUTABLE TO ALS
AND/OR ITS TREATMENT?
YES

NO

(If "Yes," complete Item 6B)

6B. DOES THE VETERAN'S MENTAL DISORDER, AS IDENTIFIED IN ITEM 6A, RESULT IN GROSS IMPAIRMENT IN THOUGHT PROCESSES OR COMMUNICATION?

(If "Yes," ALSO complete VA Form 21-0960P-2, Mental Disorders (Other than PTSD) Disability Benefits Questionnaire)
(Schedule with appropriate provider)
(If "Yes," briefly describe the veteran's mental disorder):
YES

NO

VA FORM 21-0960C-2, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VII - HOUSEBOUND
7A. IS THE VETERAN SUBSTANTIALLY CONFINED TO HIS OR HER DWELLING AND THE IMMEDIATE PREMISES (or if institutionalized, to the ward or clinical areas)?
YES
NO (If "Yes," complete Item 7B)
(If "Yes," describe how often per day or week and under what circumstances the veteran is able to leave the home or immediate premises):

7B. DOES THE VETERAN HAVE MORE THAN ONE CONDITION CONTRIBUTING TO HIS OR HER BEING HOUSEBOUND?
YES

NO

(If "Yes," list conditions and describe how each condition contributes to causing the veteran to be housebound):
Describe how condition #1 contributes to causing the veteran to be housebound:

Condition # 1:
Describe how condition #2 contributes to causing the veteran to be housebound:

Condition # 2

Condition # 3:

Describe how condition #3 contributes to causing the veteran to be housebound:

7C. IF THE VETERAN HAS ADDITIONAL CONDITIONS CONTRIBUTING TO CAUSING THE VETERAN TO BE HOUSEBOUND, LIST USING FORMAT SHOWN IN
ITEM 7B?

SECTION VIII - AID AND ATTENDANCE
8A. IS THE VETERAN ABLE TO DRESS OR UNDRESS HIM OR HERSELF WITHOUT ASSISTANCE?
YES

NO

(If "No," is this limitation caused by the veteran's ALS?)
Yes

No

8B. DOES THE VETERAN HAVE SUFFICIENT UPPER EXTREMITY COORDINATION AND STRENGTH TO BE ABLE TO FEED HIM OR HERSELF WITHOUT ASSISTANCE?
YES

NO

(If "No," is this limitation caused by the veteran's ALS?)
Yes

No

8C. IS THE VETERAN ABLE TO ATTEND TO THE WANTS OF NATURE (toileting) WITHOUT ASSISTANCE?
YES

NO

(If "No," is this limitation caused by the veteran's ALS?)
Yes

No

8D. IS THE VETERAN ABLE TO BATHE HIM OR HERSELF WITHOUT ASSISTANCE?
YES

NO

(If "No," is this limitation caused by the veteran's ALS?)
Yes

No

8E. IS THE VETERAN ABLE TO KEEP HIM OR HERSELF ORDINARILY CLEAN AND PRESENTABLE WITHOUT ASSISTANCE?
YES

NO

(If "No," is this limitation caused by the veteran's ALS?)
Yes

No

8F. DOES THE VETERAN NEED FREQUENT ASSISTANCE FOR ADJUSTMENT OF ANY SPECIAL PROSTHETIC OR ORTHOPEDIC APPLIANCE(S)
YES

NO

(If "Yes," describe):

NOTE: For VA purposes, "bedridden" will be that condition which actually requires that the claimant remain in bed. The fact that claimant has voluntarily taken to bed
or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice.
8G. IS THE VETERAN BEDRIDDEN?
YES

NO

(If "Yes," is it due to the veteran's ALS?)
Yes

No

8H. DOES THE VETERAN REQUIRE CARE AND/OR ASSISTANCE ON A REGULAR BASIS DUE TO HIS OR HER PHYSICAL AND/OR MENTAL DISABILITIES IN ORDER
TO PROTECT HIM OR HERSELF FROM THE HAZARDS AND/OR DANGERS INCIDENT TO HIS OR HER DAILY ENVIRONMENT?
YES

NO

(If "Yes," is it due to the veteran's ALS?)
Yes

No

8I. LIST ANY CONDITION(S), IN ADDITION TO THE VETERAN'S ALS, THAT CAUSES ANY OF THE ABOVE LIMITATIONS:

VA FORM 21-0960C-2, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IX - ASSISTIVE DEVICES

9A. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES

NO

(If "Yes," identify assistive device(s) used (check all that apply and indicate frequency)):
WHEELCHAIR

Frequency of use:

occasional

regular

constant

BRACE(S)

Frequency of use:

occasional

regular

constant

CRUTCH(ES)

Frequency of use:

occasional

regular

constant

CANE(S)

Frequency of use:

occasional

regular

constant

WALKER

Frequency of use:

occasional

regular

OTHER:

Frequency of use:

constant
occasional

regular

constant

9B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

SECTION X - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
10A. DUE TO ALS CONDITION, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS OTHER THAN
THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS? (Functions of the upper extremity include grasping, manipulation,
etc., while functions for the lower extremity include balance and propulsion, etc.)
YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROTHESIS WOULD EQUALLY SERVE THE VETERAN
NO

(If "Yes," complete Item 10B)
10B. INDICATE EXTREMITY(IES) (Check all extremities for which this applies)
RIGHT UPPER

LEFT UPPER

RIGHT LOWER

LEFT LOWER

(For each checked extremity, describe loss of effective function, identify the condition causing loss of function, and provide specific examples) (brief summary):

SECTION XI - FINANCIAL RESPONSIBILITY

11. IN YOUR JUDGMENT, IS THE VETERAN ABLE TO MANAGE HIS OR HER BENEFIT PAYMENTS IN HIS OR HER OWN BEST INTEREST, OR ABLE TO DIRECT
SOMEONE ELSE TO DO SO?
NO
YES

(If "No," provide rationale):

VA FORM 21-0960C-2, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION XII - DIAGNOSTIC TESTING
NOTE - If pulmonary function testing (PFT) is indicated due to respiratory disability, and results are in the medical record and reflect the veteran's current respiratory
function, repeat testing is not required. DLCO and bronchodilator testing is not indicated for a restrictive respiratory disability such as that caused by muscle weakness
due to ALS.
12A. HAVE PFTs BEEN PERFORMED?
YES

NO

(If "Yes," provide most recent results, if available):
FEV-1:

% predicted

Date of test:

FVC:

% predicted

Date of test:

FEV-1/FVC:

%

Date of test:

12B. IF PFTs HAVE BEEN PERFORMED, IS THE FLOW-VOLUME LOOP COMPATIBLE WITH UPPER AIRWAY OBSTRUCTION?
YES

NO

12C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

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

SECTION XIII - FUNCTIONAL IMPACT
13. DOES THE VETERAN'S ALS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of the veteran's ALS, providing one or more examples)

SECTION XIV - REMARKS
14. REMARKS (If any)

SECTION XV - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
15A. PHYSICIAN'S SIGNATURE
15D. PHYSICIAN'S PHONE AND FAX NUMBER

15B. PHYSICIAN'S PRINTED NAME

15E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

15C. DATE SIGNED
15F. 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 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
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 21-0960C-2, XXX XXXX

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