Va Form 21-0960i-1 - Persian Gulf And Afghanistan Infectious Diseases Disability Benefits Questionnaire

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OMB Approved No. 2900-0779

Respondent Burden: 15 minutes

PERSIAN GULF AND AFGHANISTAN INFECTIOUS DISEASES

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.

IMPORTANT - This questionnaire is intended solely for claims based on 38 CFR 3.317(c) Presumptive Service Connection for Infectious Disease. Therefore, this

questionnaire should only be completed for veterans who have or have had one or more of the following diseases/infections of the following agents: brucellosis,

campylobacteriosis (Campylobacter jejuni), Q-fever (Coxiella burnetii), malaria, tuberculosis (Mycobacterium tuberculosis), nontyphoid Salmonella, shigellosis

(Shigella), visceral leishmaniasis, or West Nile virus.

SECTION I - DIAGNOSIS

1. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH ANY OF THE INFECTIOUS DISEASES LISTED BELOW?

YES

(If "Yes," indicate the infectious disease(s)/agent(s) that the veteran now has or has been diagnosed with):

BRUCELLOSIS

ICD CODE:

DATE OF DIAGNOSIS:

CAMPYLOBACTER JEJUNI

ICD CODE:

DATE OF DIAGNOSIS:

COXIELLA BURNETII (Q FEVER)

ICD CODE:

DATE OF DIAGNOSIS:

MALARIA

ICD CODE:

DATE OF DIAGNOSIS:

NONTYPHOID SALMONELLA

ICD CODE:

DATE OF DIAGNOSIS:

SHIGELLA

ICD CODE:

DATE OF DIAGNOSIS:

VISCERAL LEISHMANIASIS

ICD CODE:

DATE OF DIAGNOSIS:

WEST NILE VIRUS

ICD CODE:

DATE OF DIAGNOSIS:

(TB)

MYCOBACTERIUM TUBERCULOSIS

ICD CODE:

DATE OF DIAGNOSIS:

*If TB is the only diagnosis checked, do not complete the rest of this questionnaire, instead complete VA Form 21-0960I-6, Tuberculosis Disability Benefits Questionnaire. If

any other disease(s) have been checked along with mycobacterium tuberculosis, complete the VA Form 21-0960I-6, Tuberculosis Disability Benefits Questionnaire for all

Tuberculosis-Related conditions, and ALSO complete this questionnaire, Persian Gulf and Afghanistan Infectious Diseases Disability Benefits Questionnaire.

SECTION II - MEDICAL HISTORY FOR DISEASE #1

2A. NAME OF DISEASE #1:

(including onset and course)

DESCRIBE HISTORY

OF THE VETERAN'S DISEASE #1:

2B. STATUS OF DISEASE #1:

ACTIVE

INACTIVE/TREATED AND RESOLVED

2C. IF INACTIVE, DATE DISEASE BECAME INACTIVE/RESOLVED:

2D. IF INACTIVE/RESOLVED, ARE THERE RESIDUALS DUE TO THE DISEASE?

(If "Yes," describe residuals):

YES