How to Complete the New VA Form 21-0781!

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Effective July 2024, there’s a brand-new VA Form 21-0781, statement in support of a claim for mental health conditions due to an in-service traumatic event.

This form is a crucial tool for veterans seeking to support their claims for mental health disorders, such as PTSD, depression, anxiety, and more, due to traumatic events experienced during military service.

Let’s explore what this new form is, when to use it, and how it can help bolster your mental health claim due to an in-service trauma.

Summary of Key Points

• New VA Form 21-0781: Effective July 2024, the updated VA Form 21-0781 is crucial for veterans supporting claims for mental health conditions due to in-service traumatic events.

• Types of Traumatic Events: This form covers combat, personal, and other traumatic events, helping to document PTSD, depression, anxiety, and more.

• Stressor Verification: All PTSD claims require a valid stressor event that can be verified for rating purposes. However, all other types of mental health claims do not require proof of an in-service stressor event.

• Old VA Form 21-0781a: As of June 28, 2024, the VA has discontinued VA Form 21-0781a, which was previously used to support claims for PTSD related to personal assault.

When To Use the VA Form 21-0781

Use the VA Form 21-0781 to provide a detailed statement in support of a claimed mental health disorder(s) due to in-service traumatic events.

This includes the following types of traumatic events:

• Combat Traumatic Events: Engaging in combat, experiencing fear of hostile military or terrorist activity, serving in imminent danger areas, or serving as a drone aircraft crew member.

• Personal Traumatic Events: Such as sexual assault or harassment (military sexual trauma – MST), physical assault, robbery, stalking, domestic abuse, or harassment.

• Other Traumatic Events: Involvement in car accidents, natural disasters, working on burn wards or graves registration, witnessing death or injury not caused by the enemy, or friendly fire incidents during training.

Note: While the VA considers this form optional, we strongly recommend completing and uploading it to support your VA mental health claim related to trauma. Why? Because it’s crucial to take charge and clearly explain the traumatic events that led to your mental health condition. Don’t leave it to chance—provide the VA with detailed information about what happened to you.

Pro Tip: The VA calls an in-service traumatic event a “stressor event.” Establishment of a valid stressor event is critical to proving a VA claim for PTSD.

How Does the VA Verify Stressor Events?

The VA will attempt to verify a stressor event with either direct or indirect evidence.

Stressor verification information can often be found in the veteran’s service records or other official documents.

When in doubt, VA claims adjudicators must “verify” a veteran’s stressor event through a review of information from VBA-sanctioned stressor research websites and the Official Military Activities Report (OMAR) tool.

OMAR is a VBA-sanctioned research tool that aggregates several approved data sources for stressor verification.

Bottom line: If the VA can’t verify your stressor event, your VA claim will likely be denied.

Pro Tip: All PTSD claims require a valid stressor event that can be verified for rating purposes. In contrast, other types of mental health claims do not require proof of an in-service stressor event.

Evidence Used for Direct Stressor Verification

The list below, although not all-inclusive, provides examples of the types of official service records that may be useful in direct stressor verification.

• Service personnel records (DD 214) and pay records

• Military occupation evidence

• Hazard pay records

• Service Treatment Records (STRs), which are your military medical records

• Military performance reports

• Verification that the Veteran received Combat/Imminent Danger/Hostile Fire Pay

• Unit and organizational histories

• Daily staff journals

• Operational reports-lessons learned (ORLLs)

• After action reports (AARs)

• Radio logs, deck logs, and ship histories

• Muster rolls

• Command chronologies and war diaries

• Monthly summaries and morning reports

• Newspaper clippings and online articles

• Photographic evidence

• KIA or MIA reports

Evidence Used for Indirect Stressor Verification

Examples of indirect sources of stressor event verification include, but are not limited to:

• Medical reports from civilian physicians or caregivers who treated the Veteran immediately following the incident or sometime later

• A chaplain or clergy

• A counseling facility or health clinic

• A rape crisis center or center for domestic abuse

• A faculty member

• Civilian police reports

• Statements from family members or roommates

• Statements from fellow service members

• Statement from the veteran

• Personal diaries or journals

How to Complete the New VA Form 21-0781

Section I: Veteran/Service Member’s Identification Information

• Veteran/Service Member’s Name: Enter your first, middle initial, and last name.

• Social Security Number: Provide your complete social security number.

• VA File Number: Your VA file number is your social security number. It’s optional to add it again.

• Date of Birth: Provide your date of birth in MM/DD/YYYY format.

• Veteran’s Service Number: Enter your service number if you have one. This is not required.

• Telephone Number: Include your area code and phone number. For international numbers, include the country code.

• E-mail Address: Optional but recommended for quicker communication.

Section II: Traumatic Event(s) Information

Select the Type of In-Service Traumatic Event(s) Experienced:

Check all that apply:

• Combat Traumatic Event(s)

• Personal Traumatic Event(s) (not involving MST)

• Personal Traumatic Event(s) (involving MST)

• Other Traumatic Event(s)

Description of the Traumatic Event(s):

• 9A. Brief Description of the Traumatic Event(s): Provide a summary of each traumatic event (e.g., injury in warfare, physical assault, sexual harassment, witnessed death or injury, etc.).

• 9B. Location of the Traumatic Event(s): Specify where each event occurred (e.g., unit assignment, residence, off-base, duty station, or state).

• 9C. Date(s) the Traumatic Event(s) Occurred: Provide the dates or approximate dates (e.g., month(s) or year(s)) when each event took place.

Note: Briefly summarize the nature of the traumatic event(s) you experienced. While providing this information may be difficult, this information may help identify evidence to support your claim. If you provide name(s) of other individuals who were involved or present during the traumatic event(s),
the VA will not contact these individual(s). Please know providing name(s) is not required for VA to continue processing your claim. Use Section V: “Remarks” if additional space is needed.

Pro Tip: Provide the VA with an approximate date of the traumatic event within a 60-day window. For example, state that the event occurred in June or July 2005. If you know the exact dates, use those. Try to be as specific and descriptive as possible.

Section III: Additional Information Associated with the In-Service Traumatic Event(s)

Indicate Any Behavioral Changes Following the In-Service Personal Traumatic Event(s):

• A. Behavioral Changes Experienced Following the Traumatic Event(s): Check all applicable changes (e.g., increased/decreased visits to a healthcare professional, requests for duty assignment changes, increased/decreased use of leave, changes in performance, episodes of depression, panic attacks, or anxiety, etc.).

• B. Additional Information About the Behavioral Changes: Provide relevant details such as the approximate time the change occurred and any documentation or records.

• C. Additional Behavioral Changes: List any other behavioral changes not included in Item 10A.

Section IV: Treatment Information

Was an Official Report Filed?

Yes: Check the appropriate box (Restricted, Unrestricted, or Neither) and provide details about the report (e.g., police report, After Action Report (AAR), incident report, formal complaint, Judge Advocate General (JAG), Criminal Investigative Division (CID), Naval Criminal Investigative Service (NCIS), etc.).

No: Skip to Item 12.

Possible Sources of Evidence Following the Traumatic Event(s):

Check all that apply:

• A rape crisis center or center for domestic abuse

• A chaplain or clergy

• A counseling facility or health clinic

• Fellow service member(s)

• Family members or roommates

• Personal diaries or journals

• A faculty member

• Civilian police reports

• Other (Specify): Medical reports from civilian physicians or caregivers who treated you immediately following the incident or sometime later

Section V: Remarks

• Remarks: This section is optional and can be used for additional space to fully answer previous questions or provide any other information that you feel is important for your claim.

Section VI: Option for VBA to Notify VHA About Certain Upcoming Events

Consent for VBA to Notify VHA:

• A. Consent: Select if you consent to have VBA notify VHA about certain upcoming events related to your claim and/or appeal.

• B. Do Not Consent: Select if you do not consent to have VBA notify VHA about these events.

• C. Revoke Prior Consent: Select if you revoke prior consent.

• D. Not Applicable: Select if not enrolled or registered in VHA healthcare.

Section VII: Certification and Signature

Certification:

• A. Veteran/Service Member’s Signature: Sign the form.

• B. Date Signed: Enter the date in MM/DD/YYYY format.

Section VIII: Witnesses to Signature (if applicable)

Witnesses to Signature:

Only use this section if the veteran/service member signed Item 16A with an “X.”

• 17A. Signature of Witness: Signature of the first witness.

• 17B. Printed Name and Address of Witness: Printed name and address of the first witness.

• 18A. Signature of Witness: Signature of the second witness.

• 18B. Printed Name and Address of Witness: Printed name and address of the second witness.

Section IX: Alternate Signer Certification and Signature (if applicable)

Alternate Signer Certification and Signature:

• A. Alternate Signer’s Signature: Signature of the alternate signer.

• B. Date Signed: Enter the date in MM/DD/YYYY format.

Section X: Power of Attorney (POA) Signature (if applicable)

POA Signature:

• A. POA/Authorized Representative’s Signature: Signature of the POA or authorized representative.

• B. Date Signed: Enter the date in MM/DD/YYYY format.

• C. Accreditation Number: Provide the accreditation number.

• D. Date Last VA Form 21-22 or 21-22a Submitted: Provide the date, if known.

Evidence That Can Be Used to Support Your Mental Health VA Claim

The VA will use the evidence submitted with your claim and either obtain or attempt to obtain additional evidence (as needed) to support your mental health claim:

• For mental health disorders related to combat, personal, or other traumatic events: Service treatment records and personnel records can support the occurrence of the traumatic event(s). VA medical records, private health records, DBQs, and Nexus Letters are also helpful.

• For PTSD related to personal traumatic events: Alternative sources of evidence or behavioral changes (e.g., changes in work performance, substance abuse, social behavior) can also support your claim. Your personal statement and testimony is also helpful.

Note: The VA will obtain and request your service treatment records, personnel records, and any other Federal records you identify. Lay testimony can be used if individual(s) or witnesses have knowledge of the traumatic event(s) or behavioral changes experienced after the event(s). This is extremely important if there is a lack of evidence of the traumatic event(s) or behavioral changes you experienced because of the trauma.

What Happened to the Old VA Form 21-0781a?

As of June 28, 2024, the VA has discontinued the use of the VA Form 21-0781a, Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault.

This form was previously used to get more information to support claims for PTSD related to personal assault.

The VA has since combined this form into a new pdf version of the VA Form 21-0781, Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s).

If You Need More Assistance

For questions concerning your VA claim, call 1-800-827-1000.

For claims related to MST, visit the Veterans Benefits Administration (VBA) MST Outreach Coordinator for your area.

Uploading Your Completed VA Form

You can complete, sign, and upload your VA Form 21-0781 electronically to VA.gov in-support of your mental health VA claim.

Mailing Your Completed Form

You can also mail your completed VA Form 21-0781 to:

Department of Veterans Affairs
Evidence Intake Center
P.O. Box 4444
Janesville, WI 53547-4444

Example #1: VA Form 21-0781 for PTSD Due to Combat Trauma

Here’s an example VA Form 21-0781 using the new outline in sections II and III for PTSD due to combat-related trauma.

Section II: Traumatic Event(s) Information

Select the Type of In-Service Traumatic Event(s) Experienced:

Check all that apply:

[X] Combat Traumatic Event(s)
[ ] Personal Traumatic Event(s) (not involving MST)
[ ] Personal Traumatic Event(s) (involving MST)
[ ] Other Traumatic Event(s)

Description of the Traumatic Event(s):

9A. Brief Description of the Traumatic Event(s):
While deployed to Afghanistan in 2011, I was involved in a combat operation where my unit came under heavy enemy fire. During the firefight, I witnessed the death of several fellow soldiers and sustained a shrapnel injury from an explosive device. The intense combat situation, the loss of comrades, and the personal injury I sustained have led to ongoing PTSD symptoms.

9B. Location of the Traumatic Event(s):
The event occurred in a remote village in the Kandahar province, Afghanistan, while I was assigned to the 101st Airborne Division.

9C. Date(s) the Traumatic Event(s) Occurred:
The traumatic event occurred over a period of two days, specifically on June 15 and June 16, 2011.

Section III: Additional Information Associated with the In-Service Traumatic Event(s)

Indicate Any Behavioral Changes Following the In-Service Personal Traumatic Event(s):

A. Behavioral Changes Experienced Following the Traumatic Event(s):
Check all applicable changes:
[X] Increased visits to a healthcare professional, counselor, or treatment facility
[ ] Request for a change in occupational series or duty assignment
[X] Increased use of leave
[X] Changes in performance or performance evaluations
[X] Episodes of depression, panic attacks, or anxiety
[X] Increased use of prescription medications
[ ] Increased use of over-the-counter medications
[X] Increased use of alcohol or drugs
[ ] Disciplinary or legal difficulties
[ ] Changes in eating habits, such as overeating or undereating, or significant changes in weight
[ ] Pregnancy tests around the time of the traumatic event(s)
[ ] Tests for sexually transmitted infections
[X] Economic or social behavioral changes
[ ] Changes in or breakup of a significant relationship

B. Additional Information About the Behavioral Changes:
Following the traumatic event, I began experiencing severe anxiety, panic attacks, and episodes of depression. I sought treatment at the base medical facility and was prescribed medication to manage my symptoms. My performance evaluations reflected a decline due to my inability to focus and complete tasks efficiently. I also started using alcohol as a coping mechanism, which further impacted my work and personal life. These behavioral changes began immediately after the event and have persisted since then.

C. Additional Behavioral Changes:
In addition to the above, I have become socially withdrawn and avoid situations that remind me of the combat incident. This has led to isolation from family and friends, and I have experienced significant economic challenges due to my inability to maintain consistent employment.

Example #2: VA Form 21-0781 for PTSD Due to Personal Assault

Here’s an example VA Form 21-0781 using the new outline in sections II and III for PTSD due to personal assault.

Section II: Traumatic Event(s) Information

Select the Type of In-Service Traumatic Event(s) Experienced:

Check all that apply:

[ ] Combat Traumatic Event(s)
[X] Personal Traumatic Event(s) (not involving MST)
[ ] Personal Traumatic Event(s) (involving MST)
[ ] Other Traumatic Event(s)

Description of the Traumatic Event(s):

9A. Brief Description of the Traumatic Event(s):
While stationed at Fort Bragg in 2015, I was assaulted by a fellow service member in the barracks. The assault was unprovoked and involved physical violence, including being punched and kicked repeatedly. The assault resulted in physical injuries and a concussion. The unexpected and violent nature of the assault has led to ongoing PTSD symptoms, including nightmares, flashbacks, and heightened anxiety.

9B. Location of the Traumatic Event(s):
The event occurred in the barracks at Fort Bragg, North Carolina.

9C. Date(s) the Traumatic Event(s) Occurred:
The traumatic event occurred on October 12, 2015.

Section III: Additional Information Associated with the In-Service Traumatic Event(s)

Indicate Any Behavioral Changes Following the In-Service Personal Traumatic Event(s):

A. Behavioral Changes Experienced Following the Traumatic Event(s):
Check all applicable changes:
[X] Increased visits to a healthcare professional, counselor, or treatment facility
[ ] Request for a change in occupational series or duty assignment
[X] Increased use of leave
[X] Changes in performance or performance evaluations
[X] Episodes of depression, panic attacks, or anxiety
[X] Increased use of prescription medications
[ ] Increased use of over-the-counter medications
[ ] Increased use of alcohol or drugs
[ ] Disciplinary or legal difficulties
[ ] Changes in eating habits, such as overeating or undereating, or significant changes in weight
[ ] Pregnancy tests around the time of the traumatic event(s)
[ ] Tests for sexually transmitted infections
[X] Economic or social behavioral changes
[X] Changes in or breakup of a significant relationship

B. Additional Information About the Behavioral Changes:
Following the assault, I began experiencing severe anxiety, panic attacks, and episodes of depression. I sought treatment at the base medical facility and was prescribed medication to manage my symptoms. My performance evaluations reflected a decline due to my inability to focus and complete tasks efficiently. I also started isolating myself socially, which further impacted my relationships with fellow service members and my family. These behavioral changes began immediately after the event and have persisted since then.

C. Additional Behavioral Changes:
In addition to the above, I have become socially withdrawn and avoid situations that remind me of the assault. This has led to isolation from family and friends, and I have experienced significant economic challenges due to my inability to maintain consistent employment. My personal relationships have suffered, including the end of a long-term relationship shortly after the incident.

New VA Form 21-0781 PDF Download

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