Disability Claims Preparation Checklist (Subject to the Privacy Act of 1974, as amended) Identification & Locator Information
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- Oswin Bradley
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1 Disabled American Veterans Transition Service Office 345 Davis Avenue West, Room 210 Barksdale Air Force Base, Louisiana Voice: (318) Fax: (318) Disability Claims Preparation Checklist (Subject to the Privacy Act of 1974, as amended) Identification & Locator Information Rank/Pay Grade: Name: Last/First/Middle Initial Male / Female Birth Date: / / (Circle One) Month Day Year Service Branch: [ ] USAR [ ] USN [ ] USAF [ ] USMC [ ] USCG (Current) Service Branch: [ ] USAR [ ] USN [ ] USAF [ ] USMC [ ] USCG (Prior) (Check more than one, if appropriate) Social Security Number: Military Service Number(s): (If different from your social security number or if you had one or more previously) Do you have a copy of your DD Form 214 from prior military service? Yes / No (Circle One) Military Unit, Address Symbol & Location: Duty Phone: Duty Fax: (Including Area Code & DSN Prefix If You Are Not Local) Duty Address: Building Better Lives For America s Disabled Veterans And Their Families
![Date: / / (Circle One) Month Day Year Service Branch: [ ] USAR [ ] USN [ ] USAF [ ] USMC [ ] USCG (Current) Service Branch: [ ] USAR [ ] USN [ ] USAF [ ] USMC [ ] USCG (Prior) (Check more than one,](/docs-images/48/19283139/images/page_1.jpg "if appropriate) Social Security Number: Military Service Number(s): (If different from your social security number or if you had one or more previously) Do you have a copy of your DD Form 214 from")
2 Supervisor s Rank/Pay Grade: Name: Last/First/Middle Initial Personnel Reliability Program, (PRP): Yes / No (Circle One) Flying Status, (FS): Yes / No (Circle One) Current Home Address: (Where you reside now) Number and Street or Rural Route, City or P.O.B and ZIP Current Home Phone: (Where you reside now) Including Area Code Current Home Fax: (Where you reside now) Including Area Code Current Personal Address: (Where you reside now) Permanent Home Address: (Following separation) Number and Street or Rural Route, City or P.O.B and ZIP Permanent Home Phone: (Following separation) Including Area Code Permanent Home Fax: (Following separation) Including Area Code Permanent Personal Address: (If you are changing following separation) Permanent Contact Address: (If no one else can find you) Number and Street or Rural Route, City or P.O.B and ZIP Permanent Contact Home Phone: (If no one else can find you) Including Area Code Permanent Contact Home Fax: (If no one else can find you) Including Area Code 2
3 Permanent Contact Address: (If no one else can find you) Separation Information Terminal Leave Date: / / Month Day Year Claim Submission Cut Off : / / Month Day Year Residing In Local Area Following Release/Discharge/Retirement: Yes / No (Circle One) Entered Active Duty: / / Month Day Year Release/Discharge Date: / / Month Day Year Type of Separation: [ ] Release, [ ] Discharge Medical Discharge: Yes / No (Circle One) Medical/Physical Evaluation Board: Yes / No (Circle One) Retirement Date: / / Type of Retirement: [ ] Sufficient Service, [ ] Medical, Month Day Year (TDRL or PDRL), [ ] High Year of Tenure (Circle One) Characterization: [ ] Honorable, [ ] Bad Conduct, [ ] Dishonorable, [ ] General, ([ ]Under Honorable Conditions, [ ]Under Other Than Honorable Conditions, [ ] Uncharacterized) Disability Claim Information Please bring a copy of your medical records, (military and civilian), for all periods of active, reserve and guard military service. If you are claiming dental injuries, diseases, or conditions, I will need a copy of your dental records. WARNING: The copies you provide are the VA s work copies and mine. YOU WILL NOT GET THEM BACK! In preparation for filing your Department of Veterans Affairs, (DVA), serviceconnected disability claim, please read carefully and check each applicable item(s), below. Consider aches, pains, numbness, limited motion, prickly sensation, loss of strength, broken bones, surgical procedures, breathing difficulty, etc. Ask yourself how the 3
![Discharge: Yes / No (Circle One) Medical/Physical Evaluation Board: Yes / No (Circle One) Retirement Date: / / Type of Retirement: [ ] Sufficient Service, [ ] Medical, Month Day Year (TDRL or PDRL),](/docs-images/48/19283139/images/page_3.jpg "[ ] High Year of Tenure (Circle One) Characterization: [ ] Honorable, [ ] Bad Conduct, [ ] Dishonorable, [ ] General, ([ ]Under Honorable Conditions, [ ]Under Other Than Honorable Conditions, [ ]")
4 previously listed items apply, (as appropriate), to each of the below listed injuries, diseases and/or conditions. THINK CHRONIC AND RESIDUAL NOT ACUTE AND TRANSITORY! Head = injury [ ], pain [ ], disease [ ], other [ ]. Headaches. (other than normal cycle) Neck = injury [ ], pain [ ], disease [ ], other [ ]. (Including whiplash) Jaw = injury [ ], pain [ ], disease [ ], other [ ]. (Including dental treatment injuries) Sinus = injury [ ], pain [ ], disease [ ], other [ ]. Both [ ], left [ ], right [ ]. (Including sinusitis and rhinitis) Hearing loss = both ears [ ], right [ ], left [ ]. Compare first enlistment through last separation audiograms [ ]. Tinnitus = both ears [ ], left [ ], right [ ]. (Tingling, buzzing, roaring, dial tone sounds in one or both ears) Defective vision = both eyes[ ], left [ ], right [ ]. Compare first enlistment through last separation eye examinations [ ]. Eye(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both eyes [ ], left [ ], right [ ]. Ear (s) = injury [ ], pain [ ], disease [ ], other [ ]. Both ears [ ], left [ ], right [ ]. Nose = injury [ ], pain [ ], disease [ ], difficulty breathing [ ], other [ ]. Throat = injury [ ], pain [ ], disease [ ], difficulty swallowing [ ], other [ ]. Mouth = injury [ ], pain [ ], disease [ ], difficulty breathing [ ], thickened saliva [ ], loose teeth [ ], sore gums [ ], excessive or constant bleeding [ ], other [ ]. Shoulder(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both [ ], left [ ], right [ ]. Upper Arm(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both arms [ ], left [ ], right [ ]. Elbow(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both arms [ ], left [ ], right [ ]. Forearms(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both arms [ ], left [ ], right [ ]. Wrist(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both hands [ ], left [ ], right [ ]. 4
![(Including whiplash) Jaw = injury [ ], pain [ ], disease [ ], other [ ]. (Including dental treatment injuries) Sinus = injury [ ], pain [ ], disease [ ], other [ ]. Both [ ], left [ ], right [ ].](/docs-images/48/19283139/images/page_4.jpg "(Including sinusitis and rhinitis) Hearing loss = both ears [ ], right [ ], left [ ]. Compare first enlistment through last separation audiograms [ ]. Tinnitus = both ears [ ], left [ ], right [ ].")
5 Hand(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both [ ], left [ ],right [ ]. Finger(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both hands [ ], left, right [ ]. Thumb(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both hands [ ], left, right [ ]. Lung(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both [ ], left [ ],right [ ]. Chest = injury [ ], pain [ ], disease [ ], other [ ]. Stomach = injury [ ], pain [ ], disease [ ], gastro-intestinal problems [ ], other [ ]. Hip(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both [ ], left [ ], right [ ]. Thigh(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both [ ], left [ ],right [ ]. Knee(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both [ ], left [ ],right [ ]. Lower leg(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both [ ], left [ ],right [ ]. Ankle(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both feet [ ], left, [ ], right [ ]. Foot/Feet= injury [ ], pain [ ], disease [ ], other [ ]. Both feet [ ], left [ ], right [ ]. Arch(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both feet [ ], left [ ], right [ ]. Toe(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both feet [ ], left [ ], right [ ]. Back = injury [ ], pain [ ], disease [ ], other [ ]. Lower [ ], upper [ ], both [ ]. Skin = Cancer(s) [ ], discoloration [ ], warts [ ], pimples and acne [ ], cysts [ ], rash [ ], moles [ ], lesions [ ], lumps [ ], other [ ]. Heart/cardiovascular condition(s) = Specify and Explain: Stroke(s). Shortness of breath. Fatigue. Flu-like symptoms. Dizziness. Sore muscle(s). 5
![Chest = injury [ ], pain [ ], disease [ ], other [ ]. Stomach = injury [ ], pain [ ], disease [ ], gastro-intestinal problems [ ], other [ ]. Hip(s) = injury [ ], pain [ ], disease [ ], other [ ].](/docs-images/48/19283139/images/page_5.jpg "Both [ ], left [ ], right [ ]. Thigh(s) = injury [ ], pain [ ], disease [ ], other [ ]. Both [ ], left [ ],right [ ]. Knee(s) = injury [ ], pain [ ], disease [ ], other [ ].")
6 Aching muscle(s). Diabetes = Insipitus [ ], Mellitus [ ]. Cancer(s), (Other than skin cancer(s)) = Specify and Explain: Hypertension (high blood pressure). Nerves/Anxiety = Specify and Explain: Post Traumatic Stress Disorder, (PTSD) = Specify and Explain: Personality disorder(s) = Specify and Explain: Arthritis = Location(s): Type(s): Non-freezing cold injuries = ear(s) [ ], finger(s) [ ], hand(s) [ ], toe(s) [ ], feet [ ], face [ ], other [ ]. Frostbite = ear(s) [ ], finger(s) [ ], hand(s) [ ], toe(s) [ ], feet [ ], face [ ], other [ ]. Burns = first degree [ ], second degree [ ], third degree [ ]. Location(s): Smoke-inhalation = Specify and Explain: Asthma. Bronchitis. Allergies = Specify and Explain: Scar(s) = Specify and Explain: 6
![Non-freezing cold injuries = ear(s) [ ], finger(s) [ ], hand(s) [ ], toe(s) [ ], feet [ ], face [ ], other [ ].](/docs-images/48/19283139/images/page_6.jpg "Frostbite = ear(s) [ ], finger(s) [ ], hand(s) [ ], toe(s) [ ], feet [ ], face [ ], other [ ]. Burns = first degree [ ], second degree [ ], third degree [ ].")
7 Electrical shock = Specify and Explain: Hemorrhoids. Piles. Anal incontinence. Creative organ(s) = injury [ ], disease [ ], loss [ ], loss of use [ ]. Hair loss = injury [ ], disease [ ]. Exposure(s) = insects [ ], animals [ ], asbestos [ ], herbicides [ ], mustard gas [ ], ionizing radiation [ ], environmental hazard(s) [ ], infrared beams [ ], x-rays [ ], laser beams [ ], microwaves [ ], nuclear medicine [ ], nuclear munitions [ ], fuels [ ], solvents [ ], Agent Orange [ ], other [ ] = Specify and Explain Contact with: Infectious disease(s) = Specify and Explain: Contact with: Local nationals [ ], animals [ ], insects [ ], dust [ ], other [ ] = Specify and Explain: Visceral Leishmaniasis (Kalaazar) [ ], Persian Gulf [ ], Somalia [ ], Grenada [ ], other [ ]. Side effects = immunization(s) [ ], inoculation(s) [ ], medication(s) [ ], pill(s) [ ], injection(s) [ ], other [ ] = Specify Type(s): Medication(s) = Specify and Explain: Surgery(s) = Specify and Explain: 7
![[ ], nuclear medicine [ ], nuclear munitions [ ], fuels [ ], solvents [ ], Agent Orange [ ], other [ ] = Specify and Explain Contact with: Infectious disease(s) = Specify and Explain: Contact with:](/docs-images/48/19283139/images/page_7.jpg "Local nationals [ ], animals [ ], insects [ ], dust [ ], other [ ] = Specify and Explain: Visceral Leishmaniasis (Kalaazar) [ ], Persian Gulf [ ], Somalia [ ], Grenada [ ], other [ ].")
8 Injuries and/or Residual Effects: Yes / No (Circle One) Specify and Explain: Combat Wounds and/or injuries = Specify and Explain: Non-combat wounds and/or injuries = Specify and Explain: 8
9 Any other chronic conditions, diseases, or symptoms = Specify and Explain: Remarks and/or explanations of item(s) checked: 9
10 10
11 Claimant s Year Signature Month / Day / Year Service Officer s Signature Month / Day / Year Do Not Write Below This Line Based upon your interview(s), what the individual checked or indicated, and examination of appropriate medical records, is an application for VA disability compensation warranted? Yes / No (Circle One) Office/Location: Printed Name of Service Officer completing this checklist: Last/First/Middle Initial 11
12 VA Form Part B, Page 1, SECTION I, Work Sheet What Disability Are You Claiming? (Use Your Checklist) Disability Began M/D/Y Treated From M/D/Y Treated To M/D/Y What Was The Name Of the Medical Facility Or Doctor? Where Was The Medical Facility Or Doctor Located? 12
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18 VA Form Part B, Page 2, SECTION III, Work Sheet (How My Listed Disabilities Are Related To My Military Service) 18
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