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 version of the form was released by the VA in July 2017 with the August 2014 edition obsolete. An up-to-date VA Form 21-0781a 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.

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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) SECONDARY TO PERSONAL ASSAULT
IMPORTANT: If you or someone you know is in crisis, call the Veterans Crisis Line at 1-800-273-8255 and press 1,
or 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.
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. Please complete the form in detail and be as specific as possible so that research of military records and other sources
you identify 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 INCIDENT(S)
8A. DATE FIRST INCIDENT OCCURRED (MM/DD/YYYY)
8B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)
FROM:
Month
Day
Year
TO:
Month
Day
Year
Month
Day
Year
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
OTHER SOURCES OF INFORMATION: Identify any other sources (military or non-military) that may provide information concerning the incident. If you reported the
incident to military or civilian authorities or sought help from a rape crisis center, counseling facility, or health clinic, etc., please provide the names and addresses and we will
assist you in getting the information. If the source provided treatment and you would like us to obtain the treatment records, complete VA Form 21-4142, Authorization and
Consent to Release Information to the Department of Veterans Affairs (VA), for each provider. If you confided in roommates, family members, chaplains, clergy, or fellow
service persons, you may want to ask them for a statement concerning their knowledge of the incident. These statements will help us in deciding your claim. Other sources of
information also include personal diaries or journals.
SUPERSEDES VA FORM 21-0781A, AUG 2014,
VA FORM
21-0781a
PAGE 1
WHICH WILL NOT BE USED.
JUL 2017
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) SECONDARY TO PERSONAL ASSAULT
IMPORTANT: If you or someone you know is in crisis, call the Veterans Crisis Line at 1-800-273-8255 and press 1,
or 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.
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. Please complete the form in detail and be as specific as possible so that research of military records and other sources
you identify 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 INCIDENT(S)
8A. DATE FIRST INCIDENT OCCURRED (MM/DD/YYYY)
8B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)
FROM:
Month
Day
Year
TO:
Month
Day
Year
Month
Day
Year
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
OTHER SOURCES OF INFORMATION: Identify any other sources (military or non-military) that may provide information concerning the incident. If you reported the
incident to military or civilian authorities or sought help from a rape crisis center, counseling facility, or health clinic, etc., please provide the names and addresses and we will
assist you in getting the information. If the source provided treatment and you would like us to obtain the treatment records, complete VA Form 21-4142, Authorization and
Consent to Release Information to the Department of Veterans Affairs (VA), for each provider. If you confided in roommates, family members, chaplains, clergy, or fellow
service persons, you may want to ask them for a statement concerning their knowledge of the incident. These statements will help us in deciding your claim. Other sources of
information also include personal diaries or journals.
SUPERSEDES VA FORM 21-0781A, AUG 2014,
VA FORM
21-0781a
PAGE 1
WHICH WILL NOT BE USED.
JUL 2017
VETERAN'S SOCIAL SECURITY NO.
SECTION II: STRESSFUL INCIDENT(S) (Continued)
9A. NAME
9B. ADDRESS
9D. ADDRESS
9C. NAME
9F. ADDRESS
9E. NAME
10A. DATE SECOND INCIDENT OCCURRED (MM,DD,YYYY)
10B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)
Month
Day
Year
FROM:
TO:
Month
Day
Year
Month
Day
Year
10C. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)
10D. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION, CAVALRY, SHIP)
10E. DESCRIPTION OF THE INCIDENT
OTHER SOURCES OF INFORMATION: Identify any other sources (military or non-military) that may provide information concerning the incident. If
you reported the incident to military or civilian authorities or sought help from a rape crisis center, counseling facility, or health clinic, etc., please provide
the names and addresses and we will assist you in getting the information. If the source provided treatment and you would like us to obtain the treatment
records, complete VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), for each provider. If
you confided in roommates, family members, chaplains, clergy, or fellow service persons, you may want to ask them for a statement concerning their
knowledge of the incident. These statements will help us in deciding your claim. Other sources of information also include personal diaries or journals.
11A. NAME
11B. ADDRESS
11C. NAME
11D. ADDRESS
11E. NAME
11 F. ADDRESS
PAGE 2
VA FORM 21-0781a, JUL 2017
VETERAN'S SOCIAL SECURITY NO.
SECTION II: STRESSFUL INCIDENT(S) (Continued)
12. Please provide in the space below any other information that you feel is important for us to know that may help your claim. The
following are some examples, of behavioral changes that you may have experienced following the incident(s):
visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment
substance abuse such as alcohol or drugs
sudden requests for a change in occupational series or duty assignment
increased disregard for military or civilian authority
increased use of leave without an apparent reason
obsessive behavior such as overeating or undereating
changes in performance and performance evaluations
pregnancy tests around the time of the incident
episodes of depression, panic attacks, or anxiety without an identifiable cause
tests for HIV or sexually transmitted diseases
increased or decreased use of prescription medications
unexplained economic or social behavior changes
increased use of over-the-counter medications
breakup of a primary relationship
SECTION III: VETERAN SIGNATURE
I HEREBY CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
14. DATE SIGNED (MM/DD/YYYY)
13. SIGNATURE
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 and other sources 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 and 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 21-0781a, JUL 2017

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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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?

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.

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.

Page Three.

Any behavioral changes that you may have experienced following the incident should be described in the blank space provided below the checklist.

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