VA Form 21-0781 Statement in Support of Claim for Service Connection for Post-traumatic Stress Disorder (Ptsd)

What Is a VA Form 21-0781?

VA Form 21-0781, Statement in Support of Claim for Service Connection for PTSD - also known as the VA PTSD Form 21-0781 - is a specific application form issued by the Department of Veterans Affairs (VA). The form has to be filled out by every person who is placing a claim for PTSD - or Post Traumatic Stress Disorder - with the Department. The claimants have to document the event or series of events that led to the disorder during their military service.

Veterans with a Purple Heart award, a Combat Infantryman Badge, or a Combat Action Ribbon may not be asked to fill out the form when applying for a VA disability compensation. The VA should notify you if the filing is necessary.

The latest version of the form was released by the VA in July 2017 with the August 2014 edition obsolete. An up-to-date VA Form 21-0781 fillable version is available for digital filing and download below or can be found on the VA website.

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OMB Approved No. 2900-0659
Respondent Burden: 1 hour 10 minutes
Expiration Date: 07/31/2020
VA DATE STAMP
DO NOT WRITE IN THIS SPACE
STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION
FOR POST-TRAUMATIC STRESS DISORDER (PTSD)
IMPORTANT: If you or someone you know is in crisis, call the Veterans Crisis Line at 1-800-273-8255 and press
https://www.veteranscrisisline.net/
to chat online, or send a text message to 838255 to receive
1, or visit
deaf and hard of hearing
confidential support 24 hours a day, 7 days a week, 365 days a year. Support for
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, and the full names and unit assignments of you know of who were killed or injured during the incident. Please
provide dates within at least a 60-day range and do not use nicknames. It is important that you complete the form in detail and be as
specific as possible so that research of military records 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/BENEFICARY NAME (First, Middle Initial, Last)
2. SOCIAL SECURITY NUMBER
4. DATE OF BIRTH (MM/DD/YYYY)
3. VA FILE NUMBER (If applicable)
Month
Day
Year
5. VETERAN'S SERVICE NUMBER (If applicable)
6. PREFERRED E-MAIL ADDRESS (Optional)
7A. PRIMARY TELEPHONE NUMBER (Include Area Code)
7B. SECONDARY TELEPHONE NUMBER (Include Area Code)
SECTION II: STRESSFUL INCIDENTS
8A. DATE FIRST INCIDENT OCCURRED (MM/DD/YYYY)
8B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)
Month
Day
Year
Month
Day
Year
Month
Day
Year
FROM:
TO:
8C. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)
8D. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
8E. DESCRIPTION OF THE INCIDENT
8F. MEDALS OR CITATIONS YOU RECEIVED BECAUSE OF THE INCIDENT
VA FORM
SUPERSEDES VA FORM 21-0781, AUG 2014,
21-0781
PAGE 1
JUL 2017
WHICH WILL NOT BE USED.
OMB Approved No. 2900-0659
Respondent Burden: 1 hour 10 minutes
Expiration Date: 07/31/2020
VA DATE STAMP
DO NOT WRITE IN THIS SPACE
STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION
FOR POST-TRAUMATIC STRESS DISORDER (PTSD)
IMPORTANT: If you or someone you know is in crisis, call the Veterans Crisis Line at 1-800-273-8255 and press
https://www.veteranscrisisline.net/
to chat online, or send a text message to 838255 to receive
1, or visit
deaf and hard of hearing
confidential support 24 hours a day, 7 days a week, 365 days a year. Support for
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, and the full names and unit assignments of you know of who were killed or injured during the incident. Please
provide dates within at least a 60-day range and do not use nicknames. It is important that you complete the form in detail and be as
specific as possible so that research of military records 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/BENEFICARY NAME (First, Middle Initial, Last)
2. SOCIAL SECURITY NUMBER
4. DATE OF BIRTH (MM/DD/YYYY)
3. VA FILE NUMBER (If applicable)
Month
Day
Year
5. VETERAN'S SERVICE NUMBER (If applicable)
6. PREFERRED E-MAIL ADDRESS (Optional)
7A. PRIMARY TELEPHONE NUMBER (Include Area Code)
7B. SECONDARY TELEPHONE NUMBER (Include Area Code)
SECTION II: STRESSFUL INCIDENTS
8A. DATE FIRST INCIDENT OCCURRED (MM/DD/YYYY)
8B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)
Month
Day
Year
Month
Day
Year
Month
Day
Year
FROM:
TO:
8C. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)
8D. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
8E. DESCRIPTION OF THE INCIDENT
8F. MEDALS OR CITATIONS YOU RECEIVED BECAUSE OF THE INCIDENT
VA FORM
SUPERSEDES VA FORM 21-0781, AUG 2014,
21-0781
PAGE 1
JUL 2017
WHICH WILL NOT BE USED.
VETERAN'S SOCIAL SECURITY NO.
SECTION II: STRESSFUL INCIDENTS (Continued)
NOTE: Information about persons who were killed or injured during the first incident (attach a separate sheet if more space is needed.)
(First, Middle Initial, Last)
9A. NAME OF PERSON
9B. RANK (If applicable)
9C. DATE OF INJURY/DEATH (MM/DD/YYYY)
9D. PLEASE CHECK ONE
Month
Day
Year
KILLED IN ACTION
WOUNDED IN ACTION
OTHER
KILLED NON-BATTLE
INJURED NON-BATTLE
9E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
(First, Middle Initial, Last)
10A. NAME OF PERSON
10B. RANK (If applicable)
10C. DATE OF INJURY/DEATH (MM/DD/YYYY)
10D. PLEASE CHECK ONE
Month
Day
Year
OTHER
KILLED IN ACTION
WOUNDED IN ACTION
KILLED NON-BATTLE
INJURED NON-BATTLE
10E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
11A. DATE SECOND INCIDENT OCCURRED (MM,DD,YYYY)
11B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)
Month
Day
Year
FROM:
TO:
Month
Day
Year
Month
Day
Year
11C. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)
11D. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
11E. DESCRIPTION OF THE INCIDENT
11F. MEDALS OR CITATIONS YOU RECEIVED BECAUSE OF THE INCIDENT
PAGE 2
VA FORM 21-0781, JUL 2017
VETERAN'S SOCIAL SECURITY NO.
SECTION II: STRESSFUL INCIDENTS (Continued)
NOTE: Information about persons who were killed or injured during the second incident (attach a separate sheet if more space is needed.)
(First, Middle Initial, Last)
12A. NAME OF PERSON
12B. RANK (If applicable)
12C. DATE OF INJURY/DEATH (MM/DD/YYYY)
12D. PLEASE CHECK ONE
Month
Day
Year
KILLED IN ACTION
WOUNDED IN ACTION
OTHER
KILLED NON-BATTLE
INJURED NON-BATTLE
12E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
(First, Middle Initial, Last)
13A. NAME OF PERSON
13C. DATE OF INJURY/DEATH (MM/DD/YYYY)
13B. RANK (If applicable)
13D. PLEASE CHECK ONE
Month
Day
Year
KILLED IN ACTION
WOUNDED IN ACTION
OTHER
KILLED NON-BATTLE
INJURED NON-BATTLE
13E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
14. REMARKS
SECTION III: VETERAN SIGNATURE
I HEREBY CERTIFY THAT the information I have given on this form is true and correct to the best of my knowledge and belief.
15. SIGNATURE
16. DATE SIGNED (MM/DD/YYYY)
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.
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 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 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.
PAGE 3
VA FORM 21-0781, JUL 2017

Download VA Form 21-0781 Statement in Support of Claim for Service Connection for Post-traumatic Stress Disorder (Ptsd)

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VA Form 21-0781 and 21-0781A

Another form that can be filled out to claim service-connected PTSD is the VA Form 21-0781A, which should be completed by veterans who have been diagnosed with PTSD due to a personal assault during their service that contributed to their current condition. The form asks to list the particular stressful incident or incidents and provide additional information on the event.

The VA Administration will initiate their own investigation order to assess whether the applicant is owed any benefits in connection with the incident. The applicant also has to specify all available sources and list the witnesses that may give any supporting information concerning the reported assault.

If a veteran would like the VA to obtain the treatment records from a healthcare provider, the VA Form 21-0781a should be submitted along with the Statement in Support of Claim for Service Connection Post-Traumatic Stress Disorder.

VA Form 21-0781 Instructions

The form does not have to be written in one sitting. Talk to a counselor, a friend or a therapist before beginning the work on your statement if you feel too stressed when recalling the details of the event.

You will need to have your military records at hand to fill out the form. The records will help you to identify all dates, times and places correctly. Other valuable sources of information are letters that may have been written home as well as any emails or text messages, Facebook and other social media posts, and diary entries.

Remember to include the following key points when filling out the VA 21-0781:

  • Identify the stressful service-connected incident or incidents that you feel have contributed to your current condition;
  • Provide a detailed description of what happened in every case. All of the related dates, geographic locations, units and dates of assignment should be provided in the form;
  • Use full names and provide the specific unit assignments of all of the participants of the incident that you know of;
  • Do not use nicknames or abbreviations;
  • The provided dates, if estimated, must be within a 60-day range.

Writing the PTSD claim can be extremely difficult because of a need to remember traumatic events and to be accurate about details, but it is something that has to be done. Here are the steps that you should follow:

  1. Write a stressor statement for PTSD explaining what happened to you as clearly as you can. A person reading the statement needs to be able to put themselves in your position and understand what you went through;
  2. Try to remember all the details - dates, locations etc. - and record them in the VA Form 21-0781;
  3. Make sure that a doctor has diagnosed you with PTSD and that the condition has been officially connected with your military service;
  4. File your claim. If your claim is denied after verification, you will receive clear reasons why you have been denied. You will then be able to adequately respond or file the claim again.

How to Properly Fill out VA Form 21-0781?

The applicants have to detail the in-service event which may have contributed to the claimed PTSD. The information that should be included in the veteran's best interest includes the following:

  1. The information regarding the symptoms of the disorder: how long they lasted, whether they create distress or limit the ability to function in a normal way, etc.;
  2. The applicant has to specify whether the incident included witnessing death, threatened death, an actual or threatened serious injury, or actual or threatened sexual violence. The claim should include information about the way of exposure to the event which may include:
    • Direct exposure;
    • Witnessing the trauma in person;
    • Indirect exposure by knowing that a close friend or family member underwent a particularly traumatic experience;
    • Indirect exposure by performing professional duties (e.g., first responders, collecting body parts, professionals repeatedly exposed to instances of child abuse).
  3. The information about re-experiencing the event via nightmares or flashbacks;
  4. The applicant must disclose if they specifically avoid trauma-related thoughts or feelings, people, places, conversations or activities;
  5. The claim must state whether a veteran has any negative thoughts or feelings that appeared or worsened after the event. These may include an inability to recall key features of the trauma, negative thoughts about oneself or the world, decreased interest in (pre-traumatic) activities or difficulties in experiencing positive emotions;
  6. The applicant must disclose the information about any trauma-related changes in behavior and personality, such as:
    • Irritability or aggression;
    • Risky or destructive behavior;
    • Hypervigilance;
    • Heightened startle reaction;
    • Difficulty concentrating or sleeping.
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