Va Form 21-0960i-6 - Tuberculosis Disability Benefits Questionnaire
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4OMB Control No. 2900-0779
Respondent Burden: 30 minutes
TUBERCULOSIS DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT- THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE
PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION
BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you
provide on this questionnaire as part of their evaluation in processing the veteran's claim.
SECTION I - DIAGNOSIS
(TB)
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH ACTIVE OR LATENT TUBERCULOSIS
?
YES
NO
1B. IF NO, HAS THE VETERAN HAD A POSITIVE SKIN TEST FOR TB WITHOUT ACTIVE DISEASE?
YES
NO
1C. IF NO, HAS THE VETERAN HAD A POSITIVE QUANTIFERON-TB GOLD TEST WITHOUT ACTIVE DISEASE?
YES
NO
1D. IF YES TO EITHER QUESTION A, B OR C ABOVE, PROVIDE ONLY DIAGNOSES THAT PERTAIN TO TB CONDITIONS:
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
1E. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO TB, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(Brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S CURRENT TB CONDITION
2B. IS THE VETERAN UNDERGOING TREATMENT OR HAS HE OR SHE COMPLETED TREATMENT FOR A TB CONDITION, INCLUDING ACTIVE TB, POSITIVE
(positive quantiferon-TB gold test)
SKIN TEST OR LABORATORY EVIDENCE OF TB
WITHOUT ACTIVE DISEASE?
YES
NO
IF YES, COMPLETE THE FOLLOWING:
Date treatment began:
If completed, date of completion:
If not completed, anticipated date of completion:
2C. LIST MEDICATIONS CURRENTLY OR PREVIOUSLY USED FOR TREATMENT OF TB CONDITION:
SECTION III - PULMONARY TB
3A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH PULMONARY TUBERCULOSIS?
YES
NO
IF YES, IS THE CONDITION:
ACTIVE
INACTIVE
If inactive, date condition became inactive:
SUPERSEDES VA FORM 21-0960I-6, DEC 2010,
21-0960I-6
VA FORM
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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