Va Form 21-0781a - Statement In Support Of Claim For Service Connection For Post-Traumatic Stress Disorder (Ptsd) Secondary To Personal Assault Page 3
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37. Please provide in the space below any other information that you feel is important for us to know that may help your claim. Let
us know if you experienced any of the following or other behavior changes 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
I CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
(Include Area Code)
8. SIGNATURE
9. DATE
10. TELEPHONE NUMBERS
DAYTIME
EVENING
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 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, AUG 2014
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