Va Form 21-4176 - Report Of Accidental Injury In Support Of Claim For Compensation Or Pension
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4GENERAL INSTRUCTIONS FOR
REPORT OF ACCIDENTAL INJURY IN SUPPORT OF CLAIM FOR COMPENSATION OR PENSION/
STATEMENT OF WITNESS TO ACCIDENT
VA FORM 21-4176, PARTS A & B
HOW CAN I CONTACT VA IF I HAVE
WHAT PART SHOULD I COMPLETE?
QUESTIONS?
If you are the veteran, complete only Part A "Report
If you have questions about this form, how to fill it out, or
of Accidental Injury in Support of Claim for
about benefits, you can contact VA in the following ways:
Compensation or Pension." If the accident was a
.
traffic accident, complete Sections I, II, and III of Part
By mail:
A. For all other types of accidents, complete Sections
You can locate the address of the closest
I and III of Part A.
regional office in your telephone book blue
pages under "United States Government,
If you are the witness, complete only Part B
Veterans."
"Statement of Witness to Injury."
.
By telephone:
Print all answers clearly. Answer questions as fully as
Please call one of the following telephone
possible. If an answer is "none" or "unknown," write
numbers
that. For additional space, attach a separate sheet,
1-800-827-1000
indicating the item number to which the answers
1-800-829-4833 (Hearing Impaired TDD Line)
apply.
.
By internet:
https://iris.va.gov
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, 58VA21/22/28, Compensation, Pension,
Education, and Vocational Rehabilitation and Employment Recirds Records - VA, published in the Federal Register. If you are the
veteran, your obligation to respond is required to obtain or retain benefits. If you are the witness, your obligation to respond is voluntary.
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 eligibility for compensation or pension benefits (38 U.S.C. 105, 1110,
1131, and 1521). 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 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.
VA FORM
21-4176
EXISTING STOCKS OF VA FORM 21-4176, OCT 2005,
DEC 2011
WILL BE USED.
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