[List name, dosage, frequency, and prescriber]
Examples:
The VA officially discontinued Form 21-0781a . va form 21 0781 pdf
The VA uses this form to gather specific information to look up official military logs, deck logs, unit histories, and records to verify that a traumatic incident actually occurred.
| Field | Your Information | |-------|------------------| | (Last, First, Middle) | [Your Last Name, First Name, MI] | | 2. VA FILE NUMBER (Last 4 digits of SSN) | XXX-XX-1234 → 1234 | | 3. SOCIAL SECURITY NUMBER | XXX-XX-XXXX | | 4. DATE OF CLAIM (MM/DD/YYYY) | [Today’s Date] | | 5. PLACE OF CLAIM | [City, State of VA Regional Office] | | 6. TELEPHONE NUMBER (Include Area Code) | [Your Phone Number] | | 7. EMAIL ADDRESS | [Your Email] | [List name, dosage, frequency, and prescriber] Examples: The
"Increased irritability, difficulty sleeping, avoidance of crowds or loud noises, strained family relationships, job instability, substance use, panic attacks."
: Use VA Form 21-0781a specifically for incidents involving personal assault or military sexual trauma (MST) . VA FILE NUMBER (Last 4 digits of SSN)
Describe the specific, non-combat stressful event(s) in service. Include what happened, who was involved, when, where, why, and how you were involved. Be specific. Avoid generalities.
(Month, Day, Year) 6. LOCATION OF EVENT (City, State, Country) 7. UNIT ASSIGNMENT OR ORGANIZATION AT TIME OF EVENT