STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION
FOR POST-TRAUMATIC STRESS DISORDER (PTSD)
5A. NAME OF SERVICEPERSON (First, Middle, Last)
STRESSFUL INCIDENT NO. 1
2. VA FILE NO.
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 servicepersons 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.
5C. DATE OF INJURY/DEATH (Mo., day, yr.)
3C. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,
CALVARY, SHIP)
3B. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)
5E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,
CALVARY, SHIP)
4E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,
CALVARY, SHIP)
3D. DATES OF UNIT ASSIGNMENT (Mo., day, yr.)
3E. DESCRIPTION OF THE INCIDENT
3F. MEDALS OR CITATIONS YOU RECEIVED BECAUSE OF THE INCIDENT
1. NAME OF VETERAN (First, Middle, Last)
5B. RANK
5D. PLEASE CHECK ONE
3A. DATE INCIDENT OCCURRED (Mo., day, yr.)
VA FORM
OCT 2007
21-0781
KILLED IN ACTION
KILLED NON-BATTLE
WOUNDED IN ACTION
INJURED NON-BATTLE
4A. NAME OF SERVICEPERSON (First, Middle, Last)
4C. DATE OF INJURY/DEATH (Mo., day, yr.)
4B. RANK
4D. PLEASE CHECK ONE
KILLED IN ACTION
KILLED NON-BATTLE
WOUNDED IN ACTION
INJURED NON-BATTLE
FROM
TO
INFORMATION ABOUT SERVICEPERSONS WHO WERE KILLED OR INJURED DURING INCIDENT NO. 1
(ATTACH A SEPARATE SHEET IF MORE SPACE IS NEEDED)
OMB Approved No. 2900-0659
Respondent Burden: 1 hour 10 minutes
8A. NAME OF SERVICEPERSON (First, Middle, Last)
STRESSFUL INCIDENT NO. 2
7C. DATE OF INJURY/DEATH (Mo. day, yr.)
FROM
6D. DATES OF UNIT ASSIGNMENT (Mo.,day,yr.)
TO
6E. DESCRIPTION OF THE INCIDENT
6F. MEDALS OR CITATIONS YOU RECEIVED BECAUSE OF THE INCIDENT
9. REMARKS
8B. RANK
8D. PLEASE CHECK ONE
6A. DATE INCIDENT OCCURRED (Mo.,day, yr.)
KILLED IN ACTION
KILLED NON-BATTLE
WOUNDED IN ACTION
INJURED NON-BATTLE
7E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING,
BATTALION, CALVARY, SHIP)
7A. NAME OF SERVICEPERSON (First, Middle, Last)
7B. RANK
KILLED IN ACTION
KILLED NON-BATTLE
WOUNDED IN ACTION
INJURED NON-BATTLE
8C. DATE OF INJURY/DEATH (Mo. day, yr.)
I certify that the foregoing statement(s) are true and correct to the best of my knowledge and belief.
10. SIGNATURE
11. DATE
12. TELEPHONE NUMBERS (Include Area Code)
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.
DAYTIME
EVENING
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.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
6C. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,
CALVARY, SHIP)
8E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING,
BATTALION, CALVARY, SHIP)
INFORMATION ABOUT SERVICEPERSONS WHO WERE KILLED OR INJURED DURING INCIDENT NO. 2
(ATTACH A SEPARATE SHEET IF MORE SPACE IS NEEDED)
7D. PLEASE CHECK ONE
6B. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)