RANK 4C. DATE OF INJURY/DEATH Mo. day yr. 4E. UNIT ASSIGNMENT DURING INCIDENT Such as DIVISION WING BATTALION SUPERSEDES VA FORM 21-0781 JAN 2014 WHICH WILL NOT BE USED. 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. VA FORM 21-0781 AUG 2014 PAGE 2. 1 ATTACH A SEPARATE SHEET IF MORE SPACE IS NEEDED 4A. NAME OF SERVICEPERSON First Middle Last 4D. PLEASE CHECK ONE KILLED IN ACTION WOUNDED IN ACTION KILLED NON-BATTLE INJURED NON-BATTLE VA FORM AUG 2014 21-0781 4B. OMB Approved No. 2900-0659 Respondent Burden 1 hour 10 minutes Expiration Date 8/31/2017 VA DATE STAMP DO NOT WRITE IN THIS SPACE STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION FOR POST-TRAUMATIC STRESS DISORDER PTSD INSTRUCTIONS List the stressful incident or incidents that occurred in service that you feel contributed to your current condition. For each incident provide a description of what happened the date the geographic location your unit assignment and dates of assignment and the full names and unit assignments of you know of who were killed or injured during the incident. Please provide dates within at least a 60-day range and do not use nicknames. It is important that you complete the form in detail and be as specific as possible so that research of military records can be thoroughly conducted* If more space is needed attach a separate sheet indicating the item number to which the answers apply. 1. NAME OF VETERAN First Middle Last 2. VA FILE NO. STRESSFUL INCIDENT NO. 1 3A. DATE INCIDENT OCCURRED Mo. day yr. 3B. LOCATION OF INCIDENT City State Country Province landmark or military installation 3C. UNIT ASSIGNMENT DURING INCIDENT Such as DIVISION WING BATTALION CAVALRY SHIP 3D. DATES OF UNIT ASSIGNMENT Mo. day yr. FROM TO 3E* DESCRIPTION OF THE INCIDENT 3F* MEDALS OR CITATIONS YOU RECEIVED BECAUSE OF THE INCIDENT INFORMATION ABOUT SERVICEPERSONS WHO WERE KILLED OR INJURED DURING INCIDENT NO. PAGE 1 6B. LOCATION OF INCIDENT City State Country Province landmark or military installation WING BATTALION CAVALRY SHIP 9. REMARKS I certify that the foregoing statement s are true and correct to the best of my knowledge and belief* 10. SIGNATURE 11. DATE 12. TELEPHONE NUMBERS Include Area Code DAYTIME EVENING PENALTY - The law provides severe penalties which include fine or imprisonment or both for the willful submission of any statement or evidence of a material fact knowing it is false or fraudulent acceptance of any payment to which you are not entitled* PRIVACY ACT NOTICE 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 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 VA system of records 58VA21/22/28 Compensation Pension Education and Vocational Rehabilitation and Employment Records - VA published in the Federal Register.
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