Fillable Va Form 21-0960j-3 - Prostate Cancer Disability Benefits Questionnaire (Page 3 of 3) in pdf

SECTION VII - RETROGRADE EJACULATION

7A. DOES THE VETERAN HAVE RETROGRADE EJACULATION?

YES

(If "Yes," provide etiology of the retrograde ejaculation)

7B. IF THE VETERAN HAS RETROGRADE EJACULATION, IS IT AS LIKELY AS NOT (AT LEAST A 50%PROBABILITY) ATTRIBUTABLE TO ONE OF THE DIAGNOSES

IN SECTION I, INCLUDING RESIDUALS OF TREATMENT FOR THIS DIAGNOSIS?

(If "Yes," specify the diagnosis to which the retrograde ejaculation is as likely as not attributable)

YES

SECTION VIII - RESIDUAL CONDITIONS AND/OR COMPLICATIONS

8. DOES THE VETERAN HAVE ANY OTHER RESIDUAL CONDITIONS AND/OR COMPLICATIONS DUE TO PROSTATE CANCER OR TREATMENT FOR PROSTATE

CANCER?

(If "Yes," describe):

YES

SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTIONS

9A. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED

IN SECTION I, DIAGNOSIS?

YES

(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than or equal to 39 square cm (6 square inches)

YES

(If "Yes," also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)

9B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS?

(If "Yes," describe (brief summary))

YES

SECTION X - DIAGNOSTIC TESTING

NOTE - If laboratory test results are in the medical record and reflect the veteran's current condition, repeat testing is not required.

10. 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 XI - FUNCTIONAL IMPACT

11. DOES THE VETERAN'S PROSTATE CANCER IMPACT HIS ABILITY TO WORK?

(If "Yes," describe the impact of the veteran's prostate cancer, providing one or more examples)

YES

SECTION XII - REMARKS

(If any)

12. REMARKS

SECTION XIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

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

13C. DATE SIGNED

13A. PHYSICIAN'S SIGNATURE

13B. PHYSICIAN'S PRINTED NAME

13E. PHYSICIAN'S MEDICAL LICENSE NUMBER

13F. PHYSICIAN'S ADDRESS

13D. PHYSICIAN'S PHONE AND FAX NUMBER

NOTE - VA may request additional medical information, including additional examinations, 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 15 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 3

VA FORM 21-0960J-3, OCT 2012