VA Form 21-0781 Statement in Support of Claimed Mental Health Disorder(s

ATTACHMENT TO THE STATEMENT IN SUPPORT OF CLAIMED MENTAL HEALTH DISORDER(S)
DUE TO AN IN-SERVICE TRAUMATIC EVENT(S)
When To Use This Form:
Use this form, VA Form 21-0781, Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s), to
provide a statement in support of a claimed mental health disorder(s) (e.g., posttraumatic stress disorder (PTSD), depression, anxiety, bipolar
disorder, etc.) due to an in-service traumatic event(s) to include:
• Combat traumatic event(s) (e.g., engaged in combat with the enemy, experienced fear of hostile military or terrorist activity,
served in an imminent danger area, served as a drone aircraft crew member, etc.)
• Personal traumatic event(s) (e.g., sexual assault or sexual harassment, also known as military sexual trauma (MST),
physical assault, robbery, stalking, domestic intimate partner abuse, or harassment, etc.)
• Other traumatic event(s) (e.g., involvement in car accident or natural disaster, worked on burn ward or graves registration,
witnessed the death, injury, or threat to the physical integrity of another person not caused by the enemy, or an experience that
involved friendly fire that occurred on a gunnery range during a training mission, etc.)
Note: This form is optional and not required. However, completing this form could assist with your claim. VA can use the information you
provide to review your military records and other sources of information for evidence to support your claim.

What Form Is Required:
Whether or not you complete this form, you must submit one of the following based on the type of claim sought. VA forms are
available at www.va.gov/vaforms.
If you are filing a new claim or a claim for increased disability
compensation ....

please complete and submit VA Form 21-526EZ, Application for
Disability Compensation and Related Compensation Benefits.

If you disagree with a prior decision or an evaluation (a claim after an
initial claim for the same or similar benefit was previously decided) and
have new and relevant evidence ....

please complete and submit VA Form 20-0995, Decision Review
Request: Supplemental Claim.

.

Evidence That Can Be Used to Support Your Claim:
VA will obtain or attempt to obtain evidence that supports your claim:

• If your claim is for mental health disorder(s) related to combat, personal traumatic event(s), or other traumatic

event(s), service treatment records and/or personnel records can be used to support the occurrence of the traumatic event(s).

• If your claim is for PTSD related to a personal traumatic event(s), alternative sources of evidence or changes in your behavior

such as a change in work performance, substance abuse, economic or social behavioral changes, etc. can also be used to support the
occurrence of the traumatic event(s).
NOTE: VA will obtain and/or request your service treatment records, personnel records and any other Federal records you identify.
Lay testimony can be used:

• If you have any individual(s)/witness(es) who know about the personal traumatic event(s) or would have a knowledge

of a behavioral change(s) you experienced after the personal traumatic event(s), and wants to provide a statement on
your behalf, use VA Form 21-10210, Lay/Witness Statement, and attach it or send it to the address provided in this attachment.
If your individual(s)/witness(es) is a veteran, they may be requested to provide their DD Form 214, Certificate of Uniformed Service,
or other evidence of service.

If you know of evidence not in your possession and want VA to try to get it for you:

•
•

Complete and sign VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA), and
Complete and sign VA Form 21-4142a, General Release for Medical Provider Information to the Department of
Veterans Affairs (VA), identifying any private medical records you wish VA to request for you.

If the holder of the evidence declines to give it to VA, asks for a fee to provide it, or otherwise cannot get the evidence, VA will notify you
and provide you with an opportunity to submit the information or evidence. Note: It is your responsibility to make sure we receive all
requested records that are not in the possession of a Federal department or agency.
VA FORM 21-0781, XXX XXXX

SUPERSEDES VA FORM 21-0781, JUN 2021.

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If You Need Assistance:
You may wish to contact an accredited Veterans Service Officer (VSO) to assist you with your application. For a list of accredited veterans
service organizations go to https://www.va.gov/ogc/recognizedvsos.asp. Should you need further assistance with the application process, you may
also contact your State Department(s) of Veterans Affairs at https://www.va.gov/statedva.htm.
If you have any questions concerning your claim, you may call 1-800-698-2411. If your claim is related to MST, you may also visit the
following website to locate the Veterans Benefits Administration (VBA) MST Outreach Coordinator for your area:
https://www.benefits.va.gov/benefits/mstcoordinators.asp.
For information on Veterans Health Administration (VHA) health care service, visit www.va.gov/health-care/about-va-health-benefits.
To learn more about VHA health care services available related to MST, visit www.mentalhealth.va.gov/mst or contact a VHA MST
Coordinator. A list is available at www.mentalhealth.va.gov/msthome/vha-mst-coordinators.asp or you can contact your local VA medical facility
and ask to speak to the MST Coordinator.
If you or someone you know is in crisis, call the Veterans Crisis Line at 988 and then press 1, 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.

General Information:
Want to apply electronically? You can apply online at www.va.gov. If you sign in or create an account, we can prefill parts of your
application and save your work in progress. You can also upload all your supporting documents with your claim, then track claim
status online. Get started at https://www.va.gov/disability/how-to-file-claim/.
If You Are Mailing Your Completed Form, Send To:
Department of Veterans Affairs
Evidence Intake Center
P.O. Box 4444
Janesville, WI 53547-4444

VA FORM 21-0781, XXX XXXX

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OMB Approved No. 2900-0659
Respondent Burden: 45 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

STATEMENT IN SUPPORT OF CLAIMED MENTAL HEALTH DISORDER(S)
DUE TO AN IN-SERVICE TRAUMATIC EVENT(S)
INSTRUCTIONS: Before completing this form, we encourage you to read the Privacy Act and
Respondent Burden on page 7. Use this form to provide a statement in support of a claimed mental
health disorder(s) due to an in-service traumatic event(s). For more information, you can contact us
online through Ask VA: https://ask.va.gov/ or call us toll-free at 1-800-698-2411 (TTY:711). VA forms
are available at www.va.gov/vaforms.
SECTION I: VETERAN/SERVICE MEMBER'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly and insert one
letter per box to help expedite processing of the form.
1. VETERAN/SERVICE MEMBER'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER (If applicable)

5. VETERAN'S SERVICE NUMBER (If applicable)

6. TELEPHONE NUMBER (Include Area Code)

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

Enter International Phone Number (If applicable)
7. E-MAIL ADDRESS (Optional)

SECTION II: TRAUMATIC EVENT(S) INFORMATION
8. SELECT THE TYPE OF IN-SERVICE TRAUMATIC EVENT(S) YOU EXPERIENCED (Check more than one, if applicable)
COMBAT TRAUMATIC EVENT(S)
PERSONAL TRAUMATIC EVENT(S) (not involving military sexual trauma (MST)
PERSONAL TRAUMATIC EVENT(S) (involving MST) (if checked review Section VI)
OTHER TRAUMATIC EVENT(S)

IMPORTANT: It is helpful, but not required, to complete all applicable sections of the form. Please provide information about where and when the inservice traumatic event(s) occurred. Including this information will help to identify records and sources of information that may support your claim. If
you are unable to include this information or only provide approximate dates or locations, VA will still review and consider all the evidence available
to support your claim. See the following three examples for guidance on how to complete Items 9A through 9C.
EXAMPLES OF BRIEF DESCRIPTION OF THE
TRAUMATIC EVENT(S)

EXAMPLES OF LOCATION OF THE
TRAUMATIC EVENT(S)

EXAMPLES OF DATES THE
TRAUMATIC EVENT(S) OCCURED

Example 1. Corpsman on medical ship in Da Nang harbor, Vietnam

STATIONED ON U.S.S. XYZ

SUMMER OF '70

Example 2. Mugged

BACK ALLEY IN BIG TOWN, USA

JUNE 2007

Example 3. Sexually assaulted by drill instructor

FORT XYZ

BOOT CAMP

9C. DATE(S) THE
9B. LOCATION OF THE TRAUMATIC EVENT(S)
9A. BRIEF DESCRIPTION OF THE TRAUMATIC EVENT(S)
TRAUMATIC EVENT(S) OCCURED
(e.g., unit assignment, residence, off-base,
(e.g., injury in warfare, physical assault, sexual harassment,
(e.g., month(s) or year(s), if known, or
duty station or state, if known)
witnessed the death or injury of a person, etc.)
approximate dates are acceptable)

Note: Briefly summarize the nature of the traumatic event(s) you experienced. While providing this information may be difficult, this information may
help identify evidence to support your claim. If you provide name(s) of other individuals who were involved or present during the traumatic event(s),
VA will not contact these individual(s). Please know providing name(s) is not required for VA to continue processing your claim. Use Section V:
"Remarks" if additional space is needed.
1.

2.

3.

VA FORM
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21-0781

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SECTION II: TRAUMATIC EVENT(S) INFORMATION (Continued)
4.

5.

6.
SECTION III: ADDITIONAL INFORMATION ASSOCIATED WITH THE IN-SERVICE TRAUMATIC EVENT(S)

IMPORTANT: This information will help us identify records or sources of evidence that may support your claim. If you are unable to include
this information, VA will still review and consider all the evidence available to support your claim. If additional space is needed, use
Section V: "Remarks".
Note: VA understands that in-service traumatic event(s) may not have been reported or documented. In these situations, other information,
such as behavioral changes and/or sources of evidence, may be used to support the in-service traumatic event(s).
10. INDICATE ANY BEHAVIORAL CHANGES FOLLOWING THE IN-SERVICE PERSONAL TRAUMATIC EVENT(S) (Note: Behavioral changes
can include but are not limited to the examples listed in Items 10A through 10C. If your traumatic event(s) is combat only, you may skip to Item 11.)
A. BEHAVIORAL CHANGES EXPERIENCED FOLLOWING
THE TRAUMATIC EVENT(S) (Check any box that applies)

B. ADDITIONAL INFORMATION ABOUT THE BEHAVIORAL CHANGES
(If applicable) (e.g., approximate time change occurred,
documentation, or record)

INCREASED/DECREASED VISITS TO A
HEALTHCARE PROFESSIONAL, COUNSELOR, OR
TREATMENT FACILITY

REQUEST FOR A CHANGE IN OCCUPATIONAL
SERIES OR DUTY ASSIGNMENT

INCREASED/DECREASED USE OF LEAVE

CHANGES IN PERFORMANCE OR PERFORMANCE
EVALUATIONS

EPISODES OF DEPRESSION, PANIC ATTACKS, OR
ANXIETY

INCREASED/DECREASED USE OF PRESCRIPTION
MEDICATIONS

INCREASED/DECREASED USE OF OVER-THECOUNTER MEDICATIONS

INCREASED/DECREASED USE OF ALCOHOL
OR DRUGS

DISCIPLINARY OR LEGAL DIFFICULTIES

CHANGES IN EATING HABITS, SUCH AS
OVEREATING OR UNDEREATING, OR SIGNIFICANT
CHANGES IN WEIGHT

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SECTION III: ADDITIONAL INFORMATION ASSOCIATED WITH THE IN-SERVICE TRAUMATIC EVENT(S) (Continued)
PREGNANCY TESTS AROUND THE TIME OF THE
TRAUMATIC EVENT(S)

TESTS FOR SEXUALLY TRANSMITTED INFECTIONS

ECONOMIC OR SOCIAL BEHAVIORAL CHANGES

CHANGES IN OR BREAKUP OF A SIGNIFICANT
RELATIONSHIP

C. AS NEEDED, LIST ANY ADDITIONAL BEHAVIORAL CHANGES FOLLOWING THE IN-SERVICE PERSONAL TRAUMATIC EVENT(S) THAT WERE
NOT LISTED IN ITEM 10A.

11. WAS AN OFFICIAL REPORT FILED? (Note: When reporting a sexual assault during military service, the Department of Defense offers two different reporting options,
restricted or unrestricted. Knowing the report type will help VA take the necessary steps to obtain a copy of the report. If you are unsure which report was filed, VA may
send you a follow up letter with additional information. Submitting a restricted or unrestricted report was not an option prior to 2005.)
YES (If "Yes," check the appropriate box below indicating which type of report was filed)
NO (If "No," skip to Item 12)
RESTRICTED

UNRESTRICTED

NEITHER

POLICE REPORT (Provide location, if known)
OTHER (e.g., After Action Report (AAR), incident report, formal complaint, Judge Advocate General (JAG), Criminal Investigative Division (CID),
Naval Criminal Investigative Service (NCIS), etc.)

12. POSSIBLE SOURCES OF EVIDENCE FOLLOWING THE TRAUMATIC EVENT(S) (Check all that apply) (Note: The following sources of evidence may provide
additional information for your claim. This list is not all inclusive. If you have any individual(s)/witness(es) who knows about the in-service traumatic event(s) or would
have knowledge of a behavioral change you experienced after the personal traumatic event(s), and wants to provide a statement on your behalf, use VA Form 21-10210,
Lay Witness Statement. If your individual(s)/witness(es) is a veteran, they may be requested to provide their DD Form 214, or other evidence of service.)
A RAPE CRISIS CENTER OR CENTER FOR DOMESTIC ABUSE

A CHAPLAIN OR CLERGY

A COUNSELING FACILITY OR HEALTH CLINIC

FELLOW SERVICE MEMBER(S)

FAMILY MEMBERS OR ROOMMATES

PERSONAL DIARIES OR JOURNALS

A FACULTY MEMBER

NONE

CIVILIAN POLICE REPORTS

OTHER (Specify below):

MEDICAL REPORTS FROM CIVILIAN PHYSICIANS OR
CAREGIVERS WHO TREATED YOU IMMEDIATELY FOLLOWING
THE INCIDENT OR SOMETIME LATER

SECTION IV: TREATMENT INFORMATION
13A. HAVE YOU RECEIVED TREATMENT RELATED TO THE IMPACT OF THE TRAUMATIC EVENT(S) LISTED IN ITEM 9A?
YES (If "Yes," complete Items 13B through 13E)

NO (If "No," skip to Item 14)

13B. IDENTIFY WHERE YOU HAVE RECEIVED TREATMENT (Check all that apply)
PRIVATE HEALTHCARE PROVIDER (including non-Federal records)
VA VET CENTER
COMMUNITY CARE (Paid for by VA)

VA MEDICAL CENTER(S) (VAMC) AND COMMUNITY-BASED OUTPATIENT
CLINICS (CBOC)
DEPARTMENT OF DEFENSE (DOD) MILITARY TREATMENT FACILITY(IES)
(MTF)

Note: VA has access to VAMC, CBOC, and MTF records. A consent form is not needed. However, if you would like VA to attempt to obtain your
private provider (excluding community care (paid for by VA)) or VA Vet Center health records, VA requires your consent by completing VA
Form 21-4142, and VA Form 21-4142a. VA forms are available at www.va.gov/vaforms
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SECTION IV: TREATMENT INFORMATION (Continued)
Note: If VAMC, CBOC, or MTF treatment began from 2005 to present, you do not need to provide dates in Item 13D.
13C. NAME AND LOCATION OF THE
TREATMENT FACILITY

13D. DATE(S) OF TREATMENT
(Approximate dates are acceptable)
(MM-YYYY)

13E. CHECK THE BOX IF YOU DO NOT
HAVE DATE(S) OF TREATMENT
Don't have date

Don't have date

Don't have date

SECTION V: REMARKS
Note: This section is optional and can be left blank. However, if additional space is needed to fully answer a previous question or if needed, use this
section to provide any additional information that you feel is important for us to know that may support your claim.
14. REMARKS (If any)

SECTION VI: OPTION FOR VETERANS BENEFIT ADMINISTRATION (VBA) TO NOTIFY VETRANS HEALTH ADMINISTRATION (VHA)
ABOUT CERTAIN UPCOMING EVENTS DURING THE CLAIM AND/OR APPEAL PROCESS
(Note: This section only applies if you checked personal traumatic event(s) (involving MST) in Item 8)
15. If you are filing a claim for compensation for a condition due to a personal traumatic event(s) (involving MST) and you are registered and/or
enrolled for VHA health care, you have the option for VBA to electronically notify VHA about certain upcoming event(s) during your claim and/or
appeal process. These events are any scheduled compensation and pension (C&P) examination, hearing before the Board of Veterans' Appeals,
and any decision notification. When notified, VHA will place an indicator in your medical record to alert VA health care providers that these events are
scheduled to occur. Notifications to VHA would only indicate the type of event and potential time frame, not any details specific to your claim. The
indicator in your medical record would not identify your claim as MST-related, but at this time, only claimants filing MST-related claims are provided
this notification option. For this reason, providers may know that the indicator is in relation to an MST-related claim. The decision to consent, not
consent, or revoke prior consent into the automatic notification system will not affect the status or outcome of your claim. If you would like VBA to
send these electronic notifications to VHA, please indicate your consent by selecting a check box below.
A. I CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENTS RELATED TO MY CLAIM AND/OR APPEAL (Note: I understand that an
indicator for these events will appear in my VHA medical record)
B. I DO NOT CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENTS RELATED TO MY CLAIM AND/OR APPEAL (Note: I understand
that an indicator for these events will not appear in my VHA medical record)
C. I REVOKE PRIOR CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENTS RELATED TO MY CLAIM AND/OR APPEAL (Note: I
understand that in the future, notice of these events will no longer appear in my VHA medical record)
D. NOT APPLICABLE AND/OR NOT ENROLLED OR REGISTERED IN VHA HEALTHCARE

Note: You have the option to modify your previous selection at any time. Mail your correspondence to: Department of Veterans
Affairs, Compensation Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
SECTION VII: CERTIFICATION AND SIGNATURE
I CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
16A.VETERAN/SERVICE MEMBER'S SIGNATURE

VA FORM 21-0781, XXX XXXX

16B. DATE SIGNED (MM/DD/YYYY)

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SECTION VIII: WITNESSES TO SIGNATURE
(Note: Only use this section if the veteran/service member signed Item 16A with an "X")
17A. SIGNATURE OF WITNESS

17B. PRINTED NAME AND ADDRESS OF WITNESS

18A. SIGNATURE OF WITNESS

18B. PRINTED NAME AND ADDRESS OF WITNESS

SECTION IX: ALTERNATE SIGNER CERTIFICATION AND SIGNATURE
(Note: Only required if Item 16A is blank)
NOTE: An alternate signer signature will not be accepted unless a valid VA Form 21-0972, Alternate Signer Certification, is of record or attached
to this request.
I CERTIFY THAT by signing on behalf of the claimant, that I am a court-appointed representative; OR, an attorney in fact or agent authorized to act
on behalf of a claimant under a durable power of attorney; OR, a person who is responsible for the care of the claimant, to include but not limited to a
spouse or other relative; OR, a manager or principal officer acting on behalf of an institution which is responsible for the care of an individual; AND,
that the claimant is under the age of 18; OR, is mentally incompetent to provide substantially accurate information needed to complete the form, or to
certify that the statements made on the form are true and complete; OR, is physically unable to sign this form.
I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also understand
that VA may request further documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf of the
claimant if necessary. Examples of evidence which VA may request include: Social Security Number (SSN) or Taxpayer Identification Number (TIN);
a certificate or order from a court with competent jurisdiction showing your authority to act for the claimant with a judge's signature and a date/time
stamp; copy of documentation showing appointment of fiduciary; durable power of attorney showing the name and signature of the claimant and your
authority as attorney in fact or agent; health care power of attorney, affidavit or notarized statement from an institution or person responsible for the
care of the claimant indicating the capacity or responsibility of care provided; or any other documentation showing such authorization.
19A. ALTERNATE SIGNER'S SIGNATURE

19B. DATE SIGNED (MM/DD/YYYY)

SECTION X: POWER OF ATTORNEY (POA) SIGNATURE
(Note: Only required if Item 16A is blank)
I CERTIFY THAT the claimant has authorized the undersigned representative to file this claim on behalf of the claimant and that the claimant is
aware and accepts the information provided in this document. I certify that the claimant has authorized the undersigned representative to state that
the claimant certifies the truth and completion of the information contained in this document to the best of claimant's knowledge.
Note: A POA's signature will not be accepted unless at the time of submission of this claim a valid VA Form 21-22, Appointment of Veterans
Service Organization as Claimant's Representative, or VA Form 21-22a, Appointment of Individual as Claimant's Representative, indicating the
appropriate POA is of record with VA.
20A. POA/AUTHORIZED REPRESENTATIVE'S SIGNATURE

20C. ACCREDITATION NUMBER

20B. DATE SIGNED (MM/DD/YYYY)

20D. DATE LAST VA FORM 21-22 OR VA FORM 21-22A WAS
SUBMITTED (If known)

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 Veteran Readiness and Employment
Records - VA, published in the Federal Register. Completion and submission of this form is voluntary. However, the requested information is
important to assist VA in thoroughly researching your military record and other sources to obtain supporting evidence of traumatic event(s) in service.
The responses you submit are considered confidential (38 U.S.C. 5701).
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control Number. The OMB control number for this project is 2900-0659, and it expires XX/XX/XXXX. Public reporting
burden for this collection of information is estimated to average 45 minutes per respondent, per year, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden to VA
Reports Clearance Officer at VACOPaperworkReduAct@VA.gov. Please refer to OMB Control No. 2900-0659 in any correspondence. Do not send
your completed VA Form 21-0781 to this email address.

VA FORM 21-0781, XXX XXXX

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