Va Form 21-0960m-1 - Amputations Disability Benefits Questionnaire Page 4

Download a blank fillable Va Form 21-0960m-1 - Amputations Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 21-0960m-1 - Amputations Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

SECTION X - ASSISTIVE DEVICES

10A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS

MAY BE POSSIBLE?

(If "Yes," identify assistive devices used - check all that apply and indicate frequency)

YES

Wheelchair

Frequency of use:

Occasional

Regular

Constant

Brace(s)

Frequency of use:

Occasional

Regular

Constant

Crutch(es)

Frequency of use:

Occasional

Regular

Constant

Cane(s)

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other:

Frequency of use:

Occasional

Regular

Constant

10B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

SECTION XI - DIAGNOSTIC TESTING

NOTE - Imaging studies are not required to document amputation(s)

11. ARE THERE ANY SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?

(If "Yes," provide type of test or procedure, date and results - brief summary):

YES

SECTION XII - FUNCTIONAL IMPACT

12. DOES THE VETERAN'S AMPUTATION IMPACT HIS OR HER ABILITY TO WORK?

(If "Yes," describe the impact of each of the veteran's amputations providing one or more examples):

YES

SECTION XIII - REMARKS

(If any):

13. REMARKS

SECTION XIV - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

(Sign in ink)

14B. PHYSICIAN'S PRINTED NAME

14C. DATE SIGNED

14A. PHYSICIAN'S SIGNATURE

14D. PHYSICIAN'S PHONE AND FAX NUMBER

14F. PHYSICIAN'S ADDRESS

14E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

NOTE: VA may obtain additional medical information, including an examination, if necessary to complete VA's review of the veteran's application.

IMPORTANT - Physician please fax the completed form to

(VA Regional Office FAX No.)

NOTE: A list of VA Regional Office FAX Numbers can be found at

or obtained by calling 1-800-827-1000.

PRIVACY ACT NOTICE: 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 the VA system of records, 58/VA21/22/28, Compensation,

Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. VA uses

your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account

information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide

his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is

considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information

submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this

information. We estimate that you will need an average of 30 minutes to review the instructions, find the information, and complete the 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 4

VA FORM 21-0960M-1, DEC 2014