SECTION II: STRESSFUL INCIDENT(S) (Continued)
VETERAN'S SOCIAL SECURITY NO.
10. 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
•
sudden requests for a change in occupational series or duty assignment
•
increased use of leave without an apparent reason
•
changes in performance and performance evaluations
•
episodes of depression, panic attacks, or anxiety without an identifiable cause
•
increased or decreased use of prescription medications
•
increased use of over-the-counter medications
•
substance abuse such as alcohol or drugs
•
increased disregard for military or civilian authority
•
obsessive behavior such as overeating or under eating
•
pregnancy tests around the time of the incident
•
tests for HIV or sexually transmitted diseases
•
unexplained economic or social behavior changes
•
breakup of a primary relationship
SECTION III: VETERAN SIGNATURE
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.
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).
12. DATE SIGNED (MM-DD-YYYY)
11. SIGNATURE
I HEREBY CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
VA FORM 21-0781a, JUL 2017
PAGE 3
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.
