A VA Form 21-078A is a form known as a Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault. This form is used by veterans who have already been diagnosed with PTSD as a result of the personal assault that occurred during their military service that contributed to their diagnosis. Veterans filling out this form will need to provide a detailed account of incidents that contributed to this PTSD diagnosis. These details must include the date, time, and place of the event, as well as the details of the event itself. A full account of such event/s will aid the Department of Veterans Affairs in having all the information they need to further process the form.
This form is known as a Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault. The VA Form 21-0781A is used by the United States Department of Veterans Affairs. This form will be completed by veterans who have been diagnosed with PTSD due to their military service. This form should be used by individuals who have personal assault as a contributing factor to their PTSD.
This form will ask for information about the stressful incidents that contributed to the veteran’s Post-Traumatic Stress Disorder. Details should include the date the incident occurred, where it occurred, what unit the filer was assigned to at the time, and a description of the event. The filer can include the names and addresses for people who can verify the details of this incident as well. This will ensure that the Department of Veterans Affairs can get all the information they need.
This form is commonly used by veterans who believe that their current post-traumatic stress disorder is related to a personal assault that happened while they were in service.
A VA Form 21-0781a contains the following sections:
To complete a VA Form 21-0781, you will need to provide the following information:
The 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 (example: civil or criminal law enforcement, 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) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. If the information is not furnished completely or accurately, VA will not be able to thoroughly research your military records and other sources for supporting evidence. The responses you submit are considered confidential (38 U.S.C. 5701).
The VA needs this information in order to assist you in supporting your claim for post-traumatic stress disorder (38 U.S. C. § 5107 (a)). Title 38, United States Code, allows us to ask for this information. It should take an average of 1 hour and 10 minutes to 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 www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
