VA Form 21-4176 Report of Accidental Injury in Support of Claim for Compensation or Pension

VA Form 21-4176 or the "Report Of Accidental Injury In Support Of Claim For Compensation Or Pension" is a form issued by the United States Department of Veterans Affairs.

The latest fillable PDF version of the VA 21-4176 was issued on December 1, 2011 and can be downloaded down below or found on the Veterans Affairs Forms website.

ADVERTISEMENT
GENERAL INSTRUCTIONS FOR
REPORT OF ACCIDENTAL INJURY IN SUPPORT OF CLAIM FOR COMPENSATION OR PENSION/
STATEMENT OF WITNESS TO ACCIDENT
VA FORM 21-4176, PARTS A & B
HOW CAN I CONTACT VA IF I HAVE
WHAT PART SHOULD I COMPLETE?
QUESTIONS?
If you are the veteran, complete only Part A "Report
If you have questions about this form, how to fill it out, or
of Accidental Injury in Support of Claim for
about benefits, you can contact VA in the following ways:
Compensation or Pension." If the accident was a
.
traffic accident, complete Sections I, II, and III of Part
By mail:
A. For all other types of accidents, complete Sections
You can locate the address of the closest
I and III of Part A.
regional office in your telephone book blue
pages under "United States Government,
If you are the witness, complete only Part B
Veterans."
"Statement of Witness to Injury."
.
By telephone:
Print all answers clearly. Answer questions as fully as
Please call one of the following telephone
possible. If an answer is "none" or "unknown," write
numbers
that. For additional space, attach a separate sheet,
1-800-827-1000
indicating the item number to which the answers
1-800-829-4833 (Hearing Impaired TDD Line)
apply.
.
By internet:
https://iris.va.gov
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, 58VA21/22/28, Compensation, Pension,
Education, and Vocational Rehabilitation and Employment Recirds Records - VA, published in the Federal Register. If you are the
veteran, your obligation to respond is required to obtain or retain benefits. If you are the witness, your obligation to respond is voluntary.
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 eligibility for compensation or pension benefits (38 U.S.C. 105, 1110,
1131, and 1521). 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 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.
VA FORM
21-4176
EXISTING STOCKS OF VA FORM 21-4176, OCT 2005,
DEC 2011
WILL BE USED.
GENERAL INSTRUCTIONS FOR
REPORT OF ACCIDENTAL INJURY IN SUPPORT OF CLAIM FOR COMPENSATION OR PENSION/
STATEMENT OF WITNESS TO ACCIDENT
VA FORM 21-4176, PARTS A & B
HOW CAN I CONTACT VA IF I HAVE
WHAT PART SHOULD I COMPLETE?
QUESTIONS?
If you are the veteran, complete only Part A "Report
If you have questions about this form, how to fill it out, or
of Accidental Injury in Support of Claim for
about benefits, you can contact VA in the following ways:
Compensation or Pension." If the accident was a
.
traffic accident, complete Sections I, II, and III of Part
By mail:
A. For all other types of accidents, complete Sections
You can locate the address of the closest
I and III of Part A.
regional office in your telephone book blue
pages under "United States Government,
If you are the witness, complete only Part B
Veterans."
"Statement of Witness to Injury."
.
By telephone:
Print all answers clearly. Answer questions as fully as
Please call one of the following telephone
possible. If an answer is "none" or "unknown," write
numbers
that. For additional space, attach a separate sheet,
1-800-827-1000
indicating the item number to which the answers
1-800-829-4833 (Hearing Impaired TDD Line)
apply.
.
By internet:
https://iris.va.gov
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, 58VA21/22/28, Compensation, Pension,
Education, and Vocational Rehabilitation and Employment Recirds Records - VA, published in the Federal Register. If you are the
veteran, your obligation to respond is required to obtain or retain benefits. If you are the witness, your obligation to respond is voluntary.
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 eligibility for compensation or pension benefits (38 U.S.C. 105, 1110,
1131, and 1521). 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 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.
VA FORM
21-4176
EXISTING STOCKS OF VA FORM 21-4176, OCT 2005,
DEC 2011
WILL BE USED.
OMB Control No. 2900-0104
Respondent Burden: 30 Mins.
1. VA FILE NUMBER
PART A
REPORT OF ACCIDENTAL INJURY IN SUPPORT OF CLAIM FOR COMPENSATION OR PENSION
2A. FIRST, MIDDLE, LAST NAME OF VETERAN
2B. COMPLETE MAILING ADDRESS
SECTION I
CIRCUMSTANCES OF ACCIDENT
(Identify location, such as house number, street, intersections, name or number of public highway,
3A. DATE AND TIME OF ACCIDENTAL
3B. PLACE OF ACCIDENT
INJURY
name of nearest city, name and location of military post, foreign city and country, if applicable)
4A. DID THE ACCIDENT OCCUR WHILE
4B. MILITARY ORGANIZATION
4C. AT TIME OF THE ACCIDENT, WERE YOU ON MILITARY DUTY, AUTHORIZED
(Explain fully)
YOU WERE IN THE ARMED FORCES?
OF WHICH YOU WERE A
PASS OR LEAVE, ABSENT WITHOUT LEAVE, ETC.?
MEMBER
(If "Yes," complete
YES
NO
Items 4B and 4C)
5B. EXPLAIN FULLY ANSWER TO QUESTION IN ITEM 5A
5A. WERE ALCOHOLIC INTOXICANTS,
NARCOTICS, DRUGS OR
MISCONDUCT OF ANY KIND ON THE
PART OF PERSONS CONCERNED
INVOLVED IN THIS ACCIDENT?
(If "Yes," complete
YES
NO
Item 5B)
6B. FULL NAME AND COMPLETE MAILING ADDRESS OF CIVILIAN POLICE AND/OR MILITARY POLICE WHERE SUCH
6A. DID CIVILIAN OR MILITARY POLICE
REPORT MAY BE FILED
MAKE REPORT OF THE ACCIDENT?
(If "Yes," complete
YES
NO
Item 6B)
7. FULL NAME AND MAILING ADDRESS OF THE PERSON IN WHOSE NAME THE REPORT WAS FILED
(If this was a traffic accident, complete also Items 9 through 24,
8. FULL DESCRIPTION OF HOW THE ACCIDENT OCCURRED, INCLUDING INJURIES YOU RECEIVED
Section II. Complete Section III for any type of accident)
SECTION II
REPORT OF TRAFFIC ACCIDENT
INSTRUCTIONS: Identify one vehicle as the "first vehicle". If another vehicle was involved in the accident, identify it as the "second vehicle". If
you were riding in a vehicle involved in the accident, identify it as the "first vehicle".
9. TYPE OF FIRST VEHICLE
10. TYPE OF SECOND VEHICLE
11A. WERE YOU?
11B. IN WHICH VEHICLE WERE YOU?
(If any)
DRIVER
PASSENGER
VA FORM
EXISTING STOCKS OF VA FORM 21-4176, OCT 2005,
21-4176
DEC 2011
WILL BE USED.
12. IF PASSENGER, GIVE SEAT POSITION
13. IF PEDESTRIAN, WHAT WAS YOUR POSITION IN RELATION TO VEHICLE(S)?
(If any)
14. DIRECTION OF TRAVEL OF FIRST VEHICLE
15. DIRECTION OF TRAVEL OF SECOND VEHICLE
16. APPROXIMATE SPEED OF FIRST VEHICLE
(If any)
17. APPROXIMATE SPEED OF SECOND VEHICLE
18. WHAT WERE YOU DOING PRIOR TO AND AT TIME OF ACCIDENT?
(Concrete, asphalt, etc.)
(Wet, dry, icy, etc.)
19. TYPE OF ROADWAY
20. CONDITION OF ROADWAY
(Traffic lights, road signs, obstructions, etc.)
21. TRAFFIC CONTROLS
(Clear, rain, snow, fog, etc.)
(Dawn, daylight, dusk, darkness with artificial light, darkness with no light)
22. WEATHER CONDITIONS
23. LIGHT
24. OTHER PERTINENT DETAILS
SECTION III - ALL ACCIDENTS (To be completed for any type of accident)
25. WITNESSES TO ACCIDENT
FULL NAME OF WITNESS
MAILING ADDRESS (Number and street, city, State and ZIP Code)
26. HISTORY OF TREATMENTS
MAILING ADDRESS
FULL NAME OF DOCTOR OR HOSPITAL FURNISHING
DATE
TREAT-
MENT
TREATMENT
(Number and street, city, State and ZIP Code)
TREATED
FIRST
AID
SECOND
THIRD
CERTIFICATION: I hereby certify that the entries made herein are true and correct to the best of my knowledge and belief.
27. SIGNATURE OF VETERAN OR FIDUCIARY
28. DATE
WITNESS(ES) TO SIGNATURE OF VETERAN IF MADE BY "X" MARK
NOTE: Signature made by mark must be witnessed by two persons to whom the veteran is personally known and the signatures and addresses of the
witnesses must be entered below.
29A. SIGNATURE OF WITNESS
(Number and street, city, State and ZIP Code)
29B. ADDRESS OF WITNESS
30A. SIGNATURE OF WITNESS
(Number and street, city, State and ZIP Code)
30B. ADDRESS OF WITNESS
VA FORM 21-4176, DEC 2011
DETACH AND
RETURN TO VA
REGIONAL OFFICE
1. VETERAN'S FILE NUMBER
STATEMENT OF WITNESS TO ACCIDENT
PART B
NOTE: If you know the facts and circumstances relating to the injury received by the veteran, please complete the following questions
as fully as possible. Please sign and return the completed statement to the appropriate VA regional office. You may use the reverse
or attach additional sheets if necessary.
CALL THE NEAREST VA OFFICE TOLL- FREE WITH QUESTIONS: 1-800-827-1000 (HEARING IMPAIRED TDD 1-800-829-4833)
2A. FIRST, MIDDLE, LAST NAME OF WITNESS
2B. COMPLETE MAILING ADDRESS
3. DID YOU SEE THE ACCIDENT?
(Time and date)
4. WHEN DID IT HAPPEN
YES
NO
(Identify location, such as house number, street, intersections, name or number of public highway, name and location of military
5. WHERE DID IT HAPPEN
post, foreign city and country, if applicable)
6. WHERE WERE YOU WHEN THE ACCIDENT HAPPENED?
7. WHAT WAS THE VETERAN DOING PRIOR TO AND AT THE TIME OF THE ACCIDENT?
(If more space is needed, use reverse or attach a separate sheet)
8. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED
(If more space is needed, use reverse or attach a separate sheet)
9. IN YOUR OPINION, WHAT WAS THE CAUSE OF THE ACCIDENT?
10A. IN YOUR OPINION, WAS THE VETERAN
10B. EXPLAIN FULLY YOUR ANSWER TO ITEM 10A
UNDER THE INFLUENCE OF ANY
ALCOHOLIC INTOXICANTS, NARCOTICS
OR DRUGS WHEN THE ACCIDENT HAPPENED?
(If "Yes," complete 10B)
YES
NO
STATEMENT ON TRAFFIC ACCIDENT
INSTRUCTIONS - Identify one vehicle as the "first vehicle". If another vehicle was involved in the accident, identify it as the "second vehicle". If the
veteran was riding in one vehicle, identify it as the "first vehicle". If the veteran was not riding in a vehicle and you were in a vehicle involved in the
accident, identify that vehicle as the "first vehicle".
11. TYPE OF FIRST VEHICLE
(If any)
13A. WERE YOU
13B. IN WHICH VEHICLE WERE YOU?
12. TYPE OF SECOND VEHICLE
DRIVER
PASSENGER
(Driver, passenger, in first or second vehicle, pedestrian)
14. IF PASSENGER, GIVE SEAT POSITION
15. POSITION OF VETERAN
(If any)
16. DIRECTION OF TRAVEL OF FIRST VEHICLE
17. DIRECTION OF TRAVEL OF SECOND VEHICLE
18. APPROXIMATE SPEED OF FIRST VEHICLE
(If any)
19. APPROXIMATE SPEED OF SECOND VEHICLE
(Concrete, asphalt, etc.)
(Wet, dry, icy, etc.)
20. TYPE OF ROADWAY
21. CONDITION OF ROADWAY
(Traffic lights, road signs, obstructions, etc.)
22. TRAFFIC CONTROLS
(Clear, rain, snow, fog, etc.)
(Dawn, daylight, dusk, darkness with artificial light, darkness with no light)
23. WEATHER CONDITIONS
24. LIGHT
25. OTHER WITNESS TO THIS ACCIDENT
NAME OF WITNESS
(Number and street, city, State and ZIP Code)
MAILING ADDRESS
CERTIFICATION
I hereby certify that the entries made herein are true and correct to the best of my knowledge and belief.
26. DATE
27. SIGNATURE OF WITNESS
VA FORM 21-4176, DEC 2011

Download VA Form 21-4176 Report of Accidental Injury in Support of Claim for Compensation or Pension

1352 times
Rate
4.5(4.5 / 5) 94 votes
ADVERTISEMENT
Page of 4