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Number Title Issue Date Revision Date # Pages
21-0784 Supplemental Income Questionnaire (For Philippine Claims Only) 11/16/2005 06/2005 2
21-0788 Information Regarding Apportionment of Beneficiary's Award (Fillable) 06/07/2010 05/2009 2
21-0789 Your Rights to Representation and A Hearing (No Fill-in) 06/07/2010 02/2005 2
21-0790 Your Rights to Representation and a Hearing (Possible Overpayment) (No Fill-in) 06/07/2010 02/2005 2
21-0819 VA/DOD Joint Disability Evaluation Board Claim (Fillable) 06/07/2010 10/2009 2
21-0845 Authorization To Disclose Personal Information To a Third Party (Fillable) 06/07/2010 05/2010 2
21-0847 Request for Substitution of Claimant upon Death of Claimant (Fillable) 06/07/2010 06/2009 2
21-0960A-1 Ischemic Heart Disease (IHD) Disability Benefits Questionnaire (Fillable) 10/12/2010 05/2010 2
21-0960A-2 Artery and Vein Conditions (Vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire (Fillable) 03/15/2012 1/2011 5
21-0960A-3 Hypertension Disability Benefits Questionnaire (Fillable) 03/15/2012 01/2011 2
21-0960A-4 Heart Conditions (Including Ischemic and Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) Disability Benefits Questionnaire (Fillable) 03/15/2012 01/2011 7
21-0960B-1 Hairy Cell and Other B-Cell Leukemias Disability Benefits Questionnaire (Fillable) 10/12/2010 05/2010 2
21-0960B-2 Hematologic and Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire (Fillable) 03/15/2012 12/2010 4
21-0960C-1 Parkinson's Disease Disability Benefits Questionnaire (Fillable) 10/12/2010 05/2010 2
21-0960C-10 Peripheral Nerves Conditions (Not Including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire (Fillable) 03/15/2012 12/2010 8
21-0960C-11 Seizure Disorders (Epilepsy) Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 4
21-0960C-2 Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease) Disability Benefits Questionnaire (Fillable) 03/15/2012 12/2010 7
21-0960C-3 Cranial Nerve Conditions Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 5
21-0960C-4 Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire (Fillable) 03/15/2012 01/2011 5
21-0960C-5 Central Nervous System and Neuromuscular Diseases (Except Trau. Brain Injury, etc.) Disability Benefits Questionnaire (Fillable) 03/15/2012 02/2011 9
21-0960C-6 Narcolepsy Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 2
21-0960C-7 Fibromyalgia Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 3
21-0960C-8 Headaches (Including Migraine Headaches) Disability Benefits Questionnaire (Fillable) 03/15/2012 02/2011 3
21-0960C-9 Multiple Sclerosis (MS) Disability Benefits Questionnaire (Fillable) 03/15/2012 02/2011 9
21-0960D-1 Oral and Dental Conditions Including Mouth, Lips and Tongue (Other Than Temporomandibular Joint Conditions) Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 5
21-0960E-1 Diabetes Mellitus Disability Benefits Questionnaire (Fillable) 03/15/2012 01/2011 3
21-0960E-2 Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 4
21-0960E-3 Thyroid and Parathyroid Conditions Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 6
21-0960F-1 Scars/Disfigurement Disability Benefits Questionnaire (Fillable) 03/15/2012 01/2011 7
21-0960F-2 Skin Diseases Disability Benefits Questionnaire (Fillable) 03/15/2012 01/2011 5
21-0960G-1 Esophageal Conditions (Including gastroesophageal reflux disease (GERD), hiatal hernia and other esophageal disorders) Disability Benefits Questionnaire (Fillable) 03/15/2012 02/2011 4
21-0960G-2 Gallbladder and Pancreas Conditions Disability Benefits Questionnaire (Fillable) 03/15/2012 02/2011 4
21-0960G-3 Intestinal Conditions (Other that Surgical or Infections) (Including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis, and Diverticulitis) Disability Benefits Questionnaire (Fillable) 03/15/2012 02/2011 4
21-0960G-4 Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire (Fillable) 03/15/2012 02/2011 3
21-0960G-5 Hepatitis, Cirrhosis and Other Liver Conditions Disability Benefits Questionnaire (Fillable) 03/15/2012 02/2011 5
21-0960G-6 Peritoneal Adhesions Disability Benefits Questionnaire (Fillable) 03/15/2012 02/2011 2
21-0960G-7 Stomach and Duodenal Conditions (Not Including Gerd or Esophageal Disorders) Benefits Questionnaire (Fillable) 03/15/2012 02/2011 5
21-0960G-8 Infectious Intestinal Disorders, Including Bacterial and Parasitic Infections Disability Benefits Questionnaire (Fillable) 03/15/2012 02/2011 3
21-0960H-1 Hernias (Including Abdominal, Inguinal and Femoral Hernias) Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 3
21-0960H-2 Rectum and Anus Conditions IIncluding Hemorrhoids) Benefits Questionnaire (Fillable) 03/15/2012 02/2011 3
21-0960I-1 Persian Gulf and Afghanistan Infectious Diseases Disability Benefits Questionnaire (Fillable) 03/15/2012 12/2010 2
21-0960I-2 HIV - Related Illnesses Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 5
21-0960I-3 Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 3
21-0960I-4 Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 6
21-0960I-5 Nutritional Deficiencies Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 2
21-0960I-6 Tuberculosis Disability Benefits Questionnaire (Fillable) 03/15/2012 12/2010 4
21-0960J-1 Kidney Conditions (Nephrology) Disability Benefits Questionnaire (Fillable) 03/15/2012 12/2010 5
21-0960J-2 Male Reproductive Organ Conditions Disability Benefits Questionnaire (Fillable) 03/15/2012 12/2010 6
21-0960J-3 Prostate Cancer Disability Benefits Questionnaire (Fillable) 03/15/2012 12/2010 3
21-0960J-4 Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire (Fillable) 03/15/2012 03/2011 4
 
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