Va Form 21-0781a - Statement In Support Of Claim For Service Connection For Post-Traumatic Stress Disorder (Ptsd) Secondary To Personal Assault

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OMB Approved No. 2900-0659

Respondent Burden: 1 hour 10 minutes

Expiration Date: 8/31/2017

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

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.

(First, Middle, Last)

2. VA FILE NO.

1. NAME OF VETERAN

STRESSFUL INCIDENT NO. 1

(Mo., day, yr.)

(City, State, Country, Province, landmark or military installation)

3A. DATE INCIDENT OCCURRED

3B. LOCATION OF INCIDENT

(Mo., day, yr.)

(Such as, DIVISION, WING, BATTALION,

3D. DATES OF UNIT ASSIGNMENT

3C. UNIT ASSIGNMENT DURING INCIDENT

CAVALRY, SHIP)

FROM

3E. DESCRIPTION OF THE INCIDENT

4. 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.

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

VA FORM