VA Form 21-0781A Statement in Support of Claim for Service Connection for Posttraumatic Stress Disorder (PTSD) Secondary to Personal Assault

What Is a VA Form 21-0781A?

VA Form 21-0781A, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault is a form issued by the Department of Veterans Affairs (VA) and filed by veterans who have been diagnosed with PTSD caused by their military service. A personal assault is a primary reason for filling out the form.

The latest release of the form happened in July 2017 with the August 2014 edition obsolete. An up-to-date VA Form 21-0781A is available for digital filing and download below or can be found through the VA website.

The VA 21-0781A requests some information about the traumatic incident including the exact time, date, location and a description of the event. In addition, the filer can include names, ranks, and addresses of the people who can verify the details of the incident. Providing precise details will ensure that the VA can get all the information they need to accept the claim.

VA Form 21-0781, Statement in Support of Claim for Service Connection for Post-traumatic Stress Disorder (PTSD) is a related form and is the main part of placing a claim for PTSD with the VA.

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VA Form 21-0781A Instructions

In-service personal assault is a blanket term for several kinds of assault:

  • MST - or military sexual trauma;
  • Physical assault;
  • Domestic battery;
  • Robbery;
  • Mugging;
  • Stalking;
  • Harassment.

Both female and male veterans can be victims of personal assault. The main difficulty is that the assault is commonly not reported and victims may feel uncomfortable providing evidence to support their claim.

Legally, a veteran can support their PTSD claim with several types of evidence based on personal information. This evidence may include:

  • Records from law enforcement authorities;
  • Statements from rape crisis centers and mental health counseling centers;
  • Records from hospitals or physicians;
  • Pregnancy tests or tests for STDs;
  • Statements from family members, roommates or fellow servicemembers.

The VA Form 21-0781A requires a set of specific supporting paperwork. These documents include:

  1. A diagnosis of PTSD from your healthcare provider;
  2. A statement from your provider in the form of a letter or as a note;

"After reviewing ___________'s medical records it is my opinion, more likely than not, her/his PTSD, Depression/Anxiety (PTSD, Anxiety/Depression - whatever it specifically is you filed for in your claim and must match exactly) is a direct result of military sexual trauma s/he experienced while serving on active duty";

  1. Physical evidence supporting your case;
  2. A Global Assessment of Functioning (GAF) score assigned by your provider. The GAF is a scoring system used by mental health professionals to assess how well an individual is functioning in their daily lives.

The VA 21-0781A is distributed without any filing instructions. A step-by-step filing guide can be found below.

How to Fill Out VA Form 21-0781A?

  1. Page One. The applicant must describe the event as either a "sexual assault" or a "personal assault". State the names, unit information and whether the people involved have been persecuted. If you don't remember the exact date of the incident, you can estimate a three-month time frame or mention a specific season, holiday or event.
  2. Page Two. Leave the description of the second incident blank. Draw a line across the boxes and write "Not Applicable". Do not use the same form to describe another incident unless you are ready to wait: the processing time of a PTSD claim could amount to more than a year.
  3. Page Three. Any behavioral changes that you may have experienced following the incident should be described in the blank space provided below the checklist.

Download VA Form 21-0781A Statement in Support of Claim for Service Connection for Posttraumatic Stress Disorder (PTSD) Secondary to Personal Assault

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