21-0781a Statement in Support of Claim for Service Connection for

OMB Approved No. 2900-0659
Respondent Burden: 1 hour 10 minutes
Expiration Date: XX/XX/XXXX
VA DATE STAMP
DO NOT WRITE IN THIS SPACE

STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION FOR POST-TRAUMATIC
STRESS DISORDER (PTSD) SECONDARY TO PERSONAL ASSAULT
IMPORTANT: If you or someone you know is in crisis, call the Veterans Crisis Line at 1-800-273-8255 and press 1,
or visit https://www.veteranscrisisline.net/ to chat online, or send a text message to 838255 to receive confidential
support 24 hours a day, 7 days a week, 365 days a year. Support for deaf and hard of hearing individuals is available.
INSTRUCTIONS: List the stressful incident or incidents that occurred in service that you feel contributed to your current condition.
For each incident, provide a description of what happened, the date, the geographic location, your unit assignment and dates of
assignment. Please complete the form in detail and be as specific as possible so that research of military records and other sources you
identify can be thoroughly conducted. If more space is needed, attach a separate sheet, indicating the item number to which the
answers apply.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

3. VA FILE NUMBER (If applicable)

2. SOCIAL SECURITY NUMBER

5. VETERAN'S SERVICE NUMBER (If applicable)

4. DATE OF BIRTH (MM-DD-YYYY)

6. TELEPHONE NUMBER (Include Area Code)

7. E-MAIL ADDRESS (Optional)

8. DO YOU HAVE A GENDER PREFERENCE FOR YOUR EXAMINER? (Optional)
MALE

FEMALE

SECTION II: STRESSFUL INCIDENT(S)
9A. DATE FIRST INCIDENT OCCURRED (MM-DD-YYYY)

9B. DATES OF UNIT ASSIGNMENT (MM-DD-YYYY)
FROM:

TO:

9C. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)

9D. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION, CAVALRY, SHIP)

9E. DESCRIPTION OF THE INCIDENT

VA FORM
XXX XXXX

21-0781a

SUPERSEDES VA FORM 21-0781A, JUL 2017,
WHICH WILL NOT BE USED.

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VETERAN'S SOCIAL SECURITY NO.

SECTION II: STRESSFUL INCIDENT(S) (Continued)
9E. DESCRIPTION OF INCIDENT (Continued)

10. OTHER SOURCES OF INFORMATION: Identify any other sources (military or non-military) that may provide information concerning the incident in
Items 9A through 9F. If you reported the incident to military or civilian authorities or sought help from a rape crisis center, counseling facility, or health clinic,
etc., please provide the names and addresses and we will assist you in getting the information. If the source provided treatment and you would like us to
obtain the treatment records, complete VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), for
each provider. If you confided in roommates, family members, chaplains, clergy, or fellow service persons, you may want to ask them for a statement
concerning their knowledge of the incident. These statements will help us in deciding your claim. Other sources of information also include personal diaries
or journals.
10A. Name (First, Middle Initial, Last)
10B. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

10C. Name (First, Middle Initial, Last)

10D. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

10E. Name (First, Middle Initial, Last)

10F. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

VA FORM 21-0781a, XXX XXXX

City
Country

ZIP Code/Postal Code

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VETERAN'S SOCIAL SECURITY NO.

SECTION II: STRESSFUL INCIDENT(S) (Continued)
11. Please provide in the space below any other information that you feel is important for us to know that may help your claim. The following are some
examples, of behavioral changes that you may have experienced following the incident(s):
• visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment
• sudden requests for a change in occupational series or duty assignment
• increased use of leave without an apparent reason
• changes in performance and performance evaluations
• episodes of depression, panic attacks, or anxiety without an identifiable cause
• increased or decreased use of prescription medications
• increased use of over-the-counter medications

• substance abuse such as alcohol or drugs
• increased disregard for military or civilian authority
• obsessive behavior such as overeating or under eating
• pregnancy tests around the time of the incident
• tests for HIV or sexually transmitted diseases
• unexplained economic or social behavior changes
• breakup of a primary relationship

SECTION III: VETERAN SIGNATURE

I HEREBY CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
12. SIGNATURE

13. DATE SIGNED (MM-DD-YYYY)

PRIVACY ACT NOTICE: 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 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, the requested information
is necessary to obtain supporting evidence of stressful incidents in service. If the information is not furnished completely or accurately, VA will not be able to thoroughly
research your military records and other sources for supporting evidence. The responses you submit are considered confidential (38 U.S.C. 5701).
RESPONDENT BURDEN: We need this information in order to assist you in supporting your claim for post-traumatic stress disorder (38 U.S.C. 5107 (a)). Title 38,
United States Code, allows us to ask for this information. We estimate that you will need an average of 1 hour and 10 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.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.

PENALTY - The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any statement or evidence of a
material fact, knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.

VA FORM 21-0781a, XXX XXXX

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