VA Form 21-0781

			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)

1. First Name

1. Middle Initial

1. Last Name

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER (If applicable)

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

5. VETERAN'S SERVICE NUMBER (If applicable)

6. TELEPHONE NUMBER (Include Area Code)

6. International Phone Number

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) OCCURRED
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

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

9. List

9A. BRIEF DESCRIPTION OF THE TRAUMATIC EVENT(S)

9B. LOCATION OF THE TRAUMATIC EVENT(S)

9C. DATE(S) THE TRAUMATIC EVENT(S) OCCURRED

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

13C. 1

13D. 1

13E. 1

Don't have date

13C. 2

13D. 2

13E. 2

Don't have date

13C. 3

13D. 3

13E. 3

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 BENEFITS ADMINISTRATION (VBA) TO NOTIFY VETERANS 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.

15A

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)

15B

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)

15C

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)

15D

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

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

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)

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

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

20C. ACCREDITATION NUMBER

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 03/31/2027. 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.

STATEMENT IN SUPPORT OF CLAIMED MENTAL HEALTH DISORDER(S) DUE TO AN IN-SERVICE TRAUMATIC EVENT(S)

STATEMENT IN SUPPORT OF CLAIMED MENTAL HEALTH DISORDER(S)
DUE TO AN IN-SERVICE TRAUMATIC EVENT(S)