VA Form 21-4140-1 is commonly known as an Employment Questionnaire. The Department of Veterans Affairs and the Department of Defense both use this form to process a claim for disability. This form will collect personal information about a veteran including their employment history, current employment status, and previous military status. This Employment Questionnaire will require the veteran to provide his or her employment history from the previous 12 months, as well as any periods of self-employment or unemployment. Once the Department has all the necessary information, a decision will be made as to whether or not the veteran will be deemed eligible for new benefits, or if he or she will continue to receive current disability compensation benefits.
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This form is known as an Employment Questionnaire. The VA Form 21-4140-1 is used by the Department of Veterans Affairs and Department of Defense in the United States. It may be requested by the department for someone who is filing a VA disability claim. The form will require detailed information about the claimant’s current employment and previous employment history, including military service.
This form will be required in order for the Department of Veterans Affairs to verify the eligibility of the claimant for disability benefits. The claimant’s employment history for at least the past 12 months will be required. Information about self-employment or unemployment periods will also need to be included. This information will be used to determine whether or not the claimant is eligible to either receive new veterans benefits or continue to receive existing disability compensation benefits.
This form is commonly used by veterans to provide their employment history for the past 12 months to the VA. Â It is often requested by the VA when it is reviewing your VA claims.
A VA Form 21-4140-1 contains the following sections:
To complete a VA Forms 21-4140-1, you 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: to other federal agencies for the collection of money owed to the United States, litigation in which the United States is a party or has an interest, or to the Veterans Health Administration for administering VA health care or TDIU benefits) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation & Employment Records - VA, published in the Federal Register.
The Veterans Benefits Administration (VBA) needs this information to determine continued eligibility to compensation at the 100 percent rate based on individual unemployability (38 CFR 4.16). Title 38, United States Code, allows us to ask for this information. The form is two total pages and should take an average of 5 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.
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If you need additional information about this form, you should visit the VA website at www.va.gov or visit your regional office for help filling out the form.  If you have comments on the information that is collected on this form, you can write to  Veterans Benefits Administration (20M33), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420.
