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OMB Approved No. 2900-0776 Respondent Burden: 15 … · scars/disfigurement disability benefits questionnaire. ... for non-linear scars, ... scars / disfigurement disability benefits

Aug 31, 2018

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  • 1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK DUE TO SCARS OR OTHER CAUSES, LIST USING ABOVE FORMAT:

    SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE

    OMB Approved No. 2900-0776 Respondent Burden: 15 Minutes Expiration Date: 03/31/2021

    A. DESCRIBE THE HISTORY (including cause/origin and course) OF THE VETERAN'S SCAR(S) OF THE TRUNK OR EXTREMITIES (brief summary):

    IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BEFORE COMPLETING FORM.

    1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK:

    INSTRUCTIONS: Provide all linear measurements in centimeters and area measurements in centimeters squared. For non-linear scars, measure the length and width at their widest points. After measuring the scars, use the summary sections to provide the combined approximate total area for all scars in each region. If scars are too numerous to count (for example, multiple scattered shrapnel wound scars, acne scarring or pseudofolliculitis barbae), indicate TNTC and provide approximate combined total area. NOTE: For VA purposes, superficial non-linear scars are those not associated with underlying soft tissue damage, while deep non-linear scars are associated with underlying soft tissue damage.

    NOTE TO PHYSICIAN: Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire as part of their evaluation in processing the veteran's claim. VA reserves the right to confirm the authenticity of ALL DBQ's completed by private health care providers.

    SECTION I - DIAGNOSIS1A. DOES THE VETERAN HAVE ONE OR MORE SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK?

    NOYES

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

    NAME OF PATIENT/VETERAN (First, Middle Initial, Last)

    DATE OF DIAGNOSIS:

    DATE OF DIAGNOSIS:

    DATE OF DIAGNOSIS:

    ICD CODE:

    ICD CODE:

    ICD CODE:

    DIAGNOSIS # 3:

    DIAGNOSIS # 2:

    DIAGNOSIS # 1:

    Page 121-0960F-1 SUPERSEDES VA FORM 21-0960F-1, DEC 2014, WHICH WILL NOT BE USEDVA FORM MAR 2018

    SECTION II - SCARS OF THE TRUNK AND EXTREMITIES

    2-1 - MEDICAL HISTORY

    B. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES PAINFUL?

    YES NO If yes, specify the number of painful scars: 5 or more3 421

    DESCRIBE THE PAIN (if there are multiple painful scars, be sure to adequately identify which scars are painful):

    C. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES UNSTABLE, WITH FREQUENT LOSS OF COVERING OF SKIN OVER THE SCAR?

    YES NO If yes, specify the number of unstable scars: 5 or more3 421

    DESCRIBE THE LOSS OF COVERING OF SKIN OVER THE SCAR (if there are multiple unstable scars, be sure to adequately identify which scars are unstable):

    D. ARE ANY OF THE SCARS BOTH PAINFUL AND UNSTABLE?YES NO If yes, specify number of scars that are both painful and unstable: 5 or more3 421

    DESCRIBE THE LOCATION OF THESE SCARS:

    (If "Yes," complete Item 1B)

    2. DOES THE VETERAN HAVE ANY SCARS ON THE TRUNK OR EXTREMITIES (REGIONS OTHER THAN THE HEAD, FACE OR NECK)?

    YES NO (If "Yes," complete this section) (If "No," skip to Section III)

  • DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES2-2 - PHYSICAL EXAM FOR SCARS ON THE TRUNK AND EXTREMITIES

    Page 2VA FORM 21-0960F-1, MAR 2018

    SECTION II - SCARS OF THE TRUNK AND EXTREMITIES (Continued)

    F. IF THERE ARE ADDITIONAL BURN SCARS OF THE TRUNK AND EXTREMITIES, LIST USING THE SAME FORMAT:

    A. RIGHT UPPER EXTREMITY

    INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:

    If additional scars, list using same format:

    cmScar # 3:Scar # 2: cm

    cmScar # 5:

    Length and width of each deep non-linear scar:

    Deep non-linear

    Indicate types of scars and provide measurements (check all that apply):

    Not affectedAffected

    Specify location of scars on right upper extremity and number them:

    Length and width of each superficial non-linear scar:

    Length of each linear scar:

    Linear

    cm

    Scar # 4: cm

    Scar # 1: Scar # 3:

    Scar # 5: x cmcmxScar # 4:

    x cmcmxScar # 2:x cm

    If additional scars, list using same format:

    If additional scars, list using same format:

    cmx Scar # 2: x cm cmx

    Scar # 4: x cm cmxScar # 5:

    Scar # 3:Scar # 1:

    Scar # 1:

    Superficial non-linear

    B. LEFT UPPER EXTREMITY

    If additional scars, list using same format:

    cmScar # 3:Scar # 2: cm

    cmScar # 5:

    Length and width of each deep non-linear scar:

    Deep non-linear

    Indicate types of scars and provide measurements (check all that apply):

    Not affectedAffected

    Specify location of scars on left upper extremity and number them:

    Length and width of each superficial non-linear scar:

    Length of each linear scar:

    Linear

    cm

    Scar # 4: cm

    Scar # 1: Scar # 3:

    Scar # 5: x cmcmxScar # 4:

    x cmcmxScar # 2:x cm

    If additional scars, list using same format:

    If additional scars, list using same format:

    cmx Scar # 2: x cm cmx

    Scar # 4: x cm cmxScar # 5:

    Scar # 3:Scar # 1:

    Scar # 1:

    Superficial non-linear

    C. RIGHT LOWER EXTREMITY

    If additional scars, list using same format:

    cmScar # 3:Scar # 2: cm

    cmScar # 5:

    Indicate types of scars and provide measurements (check all that apply):

    Not affectedAffected

    Specify location of scars on right lower extremity and number them:

    Length of each linear scar:

    Linear

    cm

    Scar # 4: cm

    Scar # 1:

    E. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES DUE TO BURNS?

    YES NO If yes, identify each burn scar and state depth of original burn:

    Burn scar #1:

    Less than deep partial thickness

    Full thickness or sub-dermal Deep partial thickness Less than deep partial thickness

    Full thickness or sub-dermal Deep partial thickness

    Burn scar #2:

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

  • SECTION II - SCARS OF THE TRUNK AND EXTREMITIES (Continued)DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES (Continued)

    Page 3

    Length and width of each deep non-linear scar:

    Deep non-linear

    Length and width of each superficial non-linear scar:

    Scar # 1: Scar # 3:

    Scar # 5: x cmcmxScar # 4:

    x cmcmxScar # 2:x cm

    If additional scars, list using same format:

    If additional scars, list using same format:

    cmx Scar # 2: x cm cmx

    Scar # 4: x cm cmxScar # 5:

    Scar # 3:Scar # 1:

    Superficial non-linear

    D. LEFT LOWER EXTREMITY

    If additional scars, list using same format:

    cmScar # 3:Scar # 2: cm

    cmScar # 5:

    Length and width of each deep non-linear scar:

    Deep non-linear

    Indicate types of scars and provide measurements (check all that apply):

    Not affectedAffected

    Specify location of scars on left lower extremity and number them:

    Length and width of each superficial non-linear scar:

    Length of each linear scar:

    Linear

    cm

    Scar # 4: cm

    Scar # 1: Scar # 3:

    Scar # 5: x cmcmxScar # 4:

    x cmcmxScar # 2:x cm

    If additional scars, list using same format:

    If additional scars, list using same format:

    cmx Scar # 2: x cm cmx

    Scar # 4: x cm cmxScar # 5:

    Scar # 3:Scar # 1:

    Scar # 1:

    Superficial non-linear

    E. ANTERIOR TRUNK

    If additional scars, list using same format:

    cmScar # 3:Scar # 2: cm

    cmScar # 5:

    Length and width of each deep non-linear scar:

    Deep non-linear

    Indicate types of scars and provide measurements (check all that apply):

    Not affectedAffected

    Specify location of scars on anterior trunk and number them:

    Length and width of each superficial non-linear scar:

    Length of each linear scar:

    Linear

    cm

    Scar # 4: cm

    Scar # 1: Scar # 3:

    Scar # 5: x cmcmxScar # 4:

    x cmcmxScar # 2:x cm

    If additional scars, list using same format:

    If additional scars, list using same format:

    cmx Scar # 2: x cm cmx

    Scar # 4: x cm cmxScar # 5:

    Scar # 3:Scar # 1:

    Scar # 1:

    Superficial non-linear

    F. POSTERIOR TRUNK

    If additional scars, list using same format:

    cmScar # 3:Scar # 2: cm

    cmScar # 5:

    Indicate types of scars and provide measurements (check all that apply):

    Not affectedAffected

    Specify location of scars on posterior trunk and number them:

    Length of each linear scar:

    Linear

    cm

    Scar # 4: cm

    Scar # 1:

    Length and width of each superficial non-linear scar:

    Scar # 1: Scar # 3:

    Scar # 5: x cmcmxScar # 4:

    x cmcmxScar # 2:x cm

    If additional scars, list using same format:

    Superficial non-linear

    INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:

    VA FORM 21-0960F-1, MAR 2018

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

  • 3-1 - MEDICAL HISTORY

    Page 4

    Length and width of each deep non-linear scar:

    Deep non-linear

    If additional scars, list using same format:

    cmx Scar # 2: x cm cmx

    Scar # 4: x cm cmxScar # 5:

    Scar # 3:Scar # 1:

    SUMMARY OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIESA. SUPERFICIAL NON-LINEAR SCARS (CHECK ALL THAT APPLY AND PROVIDE APPROXIMATE COMBINED TOTAL AREA IN CENTIMETERS SQUARED FOR EACH

    AFFECTED ANATOMICAL REGION)

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Approximate total area:

    cm2Approximate total area:

    cm2

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Anterior trunk:

    Right upper extremity:

    Left upper extremity:

    Right lower extremity:

    None

    Left lower extremity:

    Posterior trunk:

    B. DEEP NON-LINEAR SCARS (CHECK ALL THAT APPLY AND PROVIDE APPROXIMATE COMBINED TOTAL AREA IN CENTIMETERS SQUARED FOR EACH AFFECTED ANATOMICAL REGION)

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Approximate total area:

    cm2Approximate total area:

    cm2

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Anterior trunk:

    Right upper extremity:

    Left upper extremity:

    Right lower extremity:

    None

    Left lower extremity:

    Posterior trunk:

    3. DOES THE VETERAN HAVE ANY SCARS OR DISFIGUREMENT OF HEAD, FACE OR NECK?SECTION III - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK

    A. DESCRIBE THE HISTORY (including cause/origin and course) OF THE VETERAN'S SCAR(S) OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK (brief summary):

    B. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK PAINFUL?

    YES NO If yes, specify the number of painful scars:DESCRIBE THE PAIN (if there are multiple painful scars, be sure to adequately identify which scars are painful):

    C. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK UNSTABLE, WITH FREQUENT LOSS OF COVERING OF SKIN OVER THE SCAR?

    YES NO If yes, specify the number of unstable scars:DESCRIBE THE LOSS OF COVERING OF SKIN OVER THE SCAR (if there are multiple unstable scars, be sure to adequately identify which scars are unstable):

    D. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK BOTH PAINFUL AND UNSTABLE?YES NO If yes, specify number of scars that are both painful and unstable:

    DESCRIBE THE LOCATION OF THESE SCARS:

    E. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK DUE TO BURNS?

    YES NO If yes, identify each burn scar and state depth of original burn:

    Burn scar #1:

    Less than deep partial thickness

    Deep partial thicknessFull thickness or sub-dermal Less than deep partial thickness

    Full thickness or sub-dermal Deep partial thickness

    Burn scar #2:

    YES NO (If "Yes," complete this section) (If "No," skip to Section IV)

    INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:

    SECTION II - SCARS OF THE TRUNK AND EXTREMITIES (Continued)DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES (Continued)

    5 or more

    5 or more3 421

    1 2 43 5 or more

    3 421

    VA FORM 21-0960F-1, MAR 2018

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

  • 3-1 - MEDICAL HISTORY (Continued)

    3-2 - PHYSICAL EXAM FOR SCARS OR DISFIGUREMENT OF THE HEAD, FACE AND NECK

    DETAILS OF SCAR OR DISFIGUREMENT FOR THE HEAD, FACE AND NECK

    Page 5

    A. IDENTIFY EACH SCAR OR DISFIGUREMENT AND PROVIDE MEASUREMENTS:

    DisfigurementScar

    Scar/Disfigurement #1

    Indicate type of impairment:

    Length and width (at widest part) of scar/disfigurement #1:

    Location of scar/disfigurement #1:

    x cm

    DisfigurementScar

    Scar/Disfigurement #2

    Indicate type of impairment:

    Length and width (at widest part) of scar/disfigurement #2:

    Location of scar/disfigurement #2:

    x cm

    DisfigurementScar

    Scar/Disfigurement #4

    Indicate type of impairment:

    Length and width (at widest part) of scar/disfigurement #4:

    Location of scar/disfigurement #4:

    x cm

    DisfigurementScar

    Scar/Disfigurement #3

    Indicate type of impairment:

    Length and width (at widest part) of scar/disfigurement #3:

    Location of scar/disfigurement #3:

    x cm

    DisfigurementScar

    Scar/Disfigurement #5

    Indicate type of impairment:

    Length and width (at widest part) of scar/disfigurement #5:

    Location of scar/disfigurement #5:

    x cm

    If additional scars or disfigurement, list using the same format:

    NOYES

    B. IS THERE ELEVATION, DEPRESSION, ADHERENCE TO UNDERLYING TISSUE, OR MISSING UNDERLYING SOFT TISSUE?

    (If yes, check all that apply):Surface contour elevated on palpation

    If checked, identify each affected scar/disfigurement:

    Scar/Disfigurement #1

    If checked, identify each affected scar/disfigurement:

    Scar/Disfigurement #5

    Scar/Disfigurement #2

    Other

    Scar/Disfigurement #3

    Scar/Disfigurement #4

    Scar/Disfigurement #1

    If checked, identify each affected scar/disfigurement:

    Scar/Disfigurement #1

    Scar/Disfigurement #4

    Scar/Disfigurement #3

    Other

    Scar/Disfigurement #2

    Scar/Disfigurement #5

    Scar/Disfigurement #5

    Scar/Disfigurement #2

    Other

    Scar/Disfigurement #3

    Scar/Disfigurement #4

    Scar/Disfigurement #1

    Scar/Disfigurement #4

    Scar/Disfigurement #3

    Other

    Scar/Disfigurement #2

    Scar/Disfigurement #5

    Surface contour depressed on palpation

    If checked, identify each affected scar/disfigurement:

    Scar adherent to underlying tissue

    Underlying soft tissue missing

    SECTION III - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK (Continued)

    F. IF THERE ARE ADDITIONAL BURN SCARS OF THE HEAD, FACE OR NECK, LIST USING THE SAME FORMAT:

    VA FORM 21-0960F-1, MAR 2018

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

  • SUMMARY OF SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE AND NECK

    DETAILS OF SCAR OR DISFIGUREMENT FOR THE HEAD, FACE AND NECK (Continued)SECTION III - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK (Continued)

    Page 6

    NOYES

    C. IS THERE ABNORMAL PIGMENTATION OR TEXTURE OF THE HEAD, FACE, OR NECK?

    Hypopigmentation

    Hyperpigmentation

    Induration and inflexibility

    Abnormal texture

    cm2

    cm2

    Describe type of abnormal texture (for example, irregular, atrophic, shiny or scaly):

    NOYES

    B. IS THERE GROSS DISTORTION OR ASYMMETRY OF FACIAL FEATURES OR VISIBLE OR PALPABLE TISSUE LOSS?

    Chin

    Ears (auricles) (If checked, specify):

    Nose Forehead Cheeks

    Complete loss of auricle

    Deformity of auricle, with loss of one-third or more of the substance

    Side:

    Side:

    Lips

    Left

    Left

    Right

    Right

    Deformity of auricle, with loss of less than one-third the substance

    Side: LeftRight

    Side:

    Eyes (including eyelids) (If checked, specify):

    Anatomical loss of eye

    Tissue loss/distortion of eyelid

    Left

    Tissue loss/distortion of eye

    Side:

    Side:

    Left

    Left

    Right

    Right

    Right

    A. PROVIDE APPROXIMATE COMBINED TOTAL AREA IN CENTIMETERS SQUARED FOR EACH CHARACTERISTIC OF DISFIGUREMENT:

    1. Approximate total area of head, face and neck with hypo- or hyperpigmented areas:

    2. Approximate total area of head, face and neck with abnormal texture:

    3. Approximate total area of head, face and neck with missing underlying soft tissue:

    4. Approximate total area of head, face and neck that is indurated and inflexible:

    cm2

    cm2

    DISTORTION OF FACIAL FEATURES AND TISSUE LOSS FOR THE HEAD, FACE AND NECK

    If yes, indicate features affected (check all that apply):

    For all checked features, provide brief description of the tissue loss, gross distortion and/or asymmetry of facial features:

    (If yes, check all that apply):

    If checked, identify each affected scar/disfigurement:

    If checked, identify each affected scar/disfigurement:

    Scar/Disfigurement #1

    Scar/Disfigurement #4

    Scar/Disfigurement #3

    Other

    Scar/Disfigurement #2

    Scar/Disfigurement #5

    Scar/Disfigurement #5

    Scar/Disfigurement #2

    Other

    Scar/Disfigurement #3

    Scar/Disfigurement #4

    Scar/Disfigurement #1

    If checked, identify each affected scar/disfigurement:

    Scar/Disfigurement #1

    Scar/Disfigurement #4

    Scar/Disfigurement #3

    Other

    Scar/Disfigurement #2

    Scar/Disfigurement #5

    Scar/Disfigurement #5

    Scar/Disfigurement #2

    Other

    Scar/Disfigurement #3

    Scar/Disfigurement #4

    Scar/Disfigurement #1

    If checked, identify each affected scar/disfigurement:

    VA FORM 21-0960F-1, MAR 2018

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

  • Page 7

    SECTION IV - MISCELLANEOUS

    NOYES

    4A. DO ANY OF THE SCARS (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK RESULT IN LIMITATION OF FUNCTION?

    LIMITATION OF FUNCTION/OTHER CONDITIONSNOTE: Complete this section for all scars or disfigurements, regardless of location.

    IF YES, INDICATE WHICH SCARS (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK ARE CAUSING THE LIMITATION AND DESCRIBE THE SPECIFIC LIMITATIONS:

    NOYES

    4B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (such as muscle or nerve damage) ASSOCIATED WITH ANY SCAR (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK?

    IF YES, DESCRIBE (brief summary):

    4C. PROVIDE COLOR PHOTOGRAPHS FOR ANY SCAR(S) OR DISFIGURING CONDITIONS OF THE HEAD, FACE AND/OR NECK.COLOR PHOTOGRAPHS

    Photographs not availablePhotographs providedPhotographs not indicated

    NOYES

    5. DOES THE VETERAN'S SCAR(S) (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK IMPACT HIS OR HER ABILITY TO WORK?SECTION V - FUNCTIONAL IMPACT

    IF YES, DESCRIBE IMPACT OF THE VETERAN'S SCAR(S) (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK, PROVIDING ONE OR MORE EXAMPLES

    SECTION VI - REMARKS

    CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current. SECTION VII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

    6. REMARKS (if any):

    VA FORM 21-0960F-1, MAR 2018

    PRIVACY ACT NOTICE: 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 the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

    RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 minutes to review the instructions, find the information, and complete the 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.

    IMPORTANT - Physician please fax the completed form to (VA Regional Office FAX No.)

    NOTE: VA may obtain additional medical information, including an examination, if necessary to complete VA's review of the veteran's application.

    NOTE: A list of VA Regional Office FAX Numbers can be found at www.benefits.va.gov/disabilityexams or obtained by calling 1-800-827-1000.

    7C. DATE SIGNED

    7F. PHYSICIAN'S ADDRESS

    7B. PHYSICIAN'S PRINTED NAME7A. PHYSICIAN'S SIGNATURE (Sign in ink)

    7E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER7D. PHYSICIAN'S PHONE AND FAX NUMBER

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

    www.reginfo.gov/public/do/PRAMainwww.benefits.va.gov/disabilityexams

    1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK DUE TO SCARS OR OTHER CAUSES, LIST USING ABOVE FORMAT:

    SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE

    OMB Approved No. 2900-0776Respondent Burden: 15 Minutes

    Expiration Date: 03/31/2021

    A. DESCRIBE THE HISTORY(including cause/origin and course) OF THE VETERAN'S SCAR(S) OF THE TRUNK OR EXTREMITIES(brief summary):

    IMPORTANT- THE DEPARTMENT OF VETERANS AFFAIRS (VA)WILL NOT PAYORREIMBURSEANY EXPENSES OR COST INCURRED IN THE PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BEFORECOMPLETING FORM.

    1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK:

    INSTRUCTIONS: Provide all linear measurements in centimeters and area measurements in centimeters squared.

    For non-linear scars, measure the length and width at their widest points.

    After measuring the scars, use the summary sections to provide the combined approximate total area for all scars in each region.

    If scars are too numerous to count (for example, multiple scattered shrapnel wound scars, acne scarring or pseudofolliculitis barbae), indicate TNTC and provide approximate combined total area.

    NOTE: For VA purposes, superficial non-linear scars are those not associated with underlying soft tissue damage, while deep non-linear scars are associated with underlying soft tissue damage.

    NOTE TO PHYSICIAN: Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits.VA will consider the information you

    provide on this questionnaire as part of their evaluation in processing the veteran's claim. VA reserves the right to confirm the authenticity of ALL DBQ's completed

    by private health care providers.

    SECTION I - DIAGNOSIS

    1A. DOES THE VETERAN HAVE ONE OR MORE SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK?

    \\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg

    Department of Veterans Affairs Logo.

    NO

    YES

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

    NAME OF PATIENT/VETERAN(First, Middle Initial, Last)

    DATE OF DIAGNOSIS:

    DATE OF DIAGNOSIS:

    DATE OF DIAGNOSIS:

    ICD CODE:

    ICD CODE:

    ICD CODE:

    DIAGNOSIS # 3:

    DIAGNOSIS # 2:

    DIAGNOSIS # 1:

    Page 1

    21-0960F-1

    SUPERSEDES VA FORM 21-0960F-1, DEC 2014,

    WHICH WILL NOT BE USED

    VAFORM

    MAR 2018

    SECTION II - SCARS OF THE TRUNK AND EXTREMITIES

    2-1 - MEDICAL HISTORY

    B. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES PAINFUL?

    YES

    NO

    If yes, specify the number of painful scars:

    5 or more

    3

    4

    2

    1

    DESCRIBE THE PAIN (if there are multiple painful scars, be sure to adequately identify which scars are painful):

    C. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES UNSTABLE, WITH FREQUENT LOSS OF COVERING OF SKIN OVER THE SCAR?

    YES

    NO

    If yes, specify the number of unstable scars:

    5 or more

    3

    4

    2

    1

    DESCRIBE THE LOSS OF COVERING OF SKIN OVER THE SCAR(if there are multiple unstable scars, be sure to adequately identify which scars are unstable):

    D. ARE ANY OF THE SCARSBOTH PAINFUL AND UNSTABLE?

    YES

    NO

    If yes, specify number of scars that are both painful and unstable:

    5 or more

    3

    4

    2

    1

    DESCRIBE THE LOCATION OF THESE SCARS:

    (If "Yes," complete Item 1B)

    2. DOES THE VETERAN HAVE ANY SCARS ON THE TRUNK OR EXTREMITIES (REGIONS OTHER THAN THE HEAD, FACE OR NECK)?

    YES

    NO

    (If "Yes," complete this section)

    (If "No," skip to Section III)

    DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES

    2-2 - PHYSICAL EXAM FOR SCARS ON THE TRUNK AND EXTREMITIES

    Page 2

    VA FORM 21-0960F-1, MAR 2018

    SECTION II - SCARS OF THE TRUNK AND EXTREMITIES(Continued)

    F. IF THERE ARE ADDITIONAL BURN SCARS OF THE TRUNK AND EXTREMITIES, LIST USING THE SAME FORMAT:

    A. RIGHT UPPER EXTREMITY

    INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:

    If additional scars, list using same format:

    cm

    Scar # 3:

    Scar # 2:

    cm

    cm

    Scar # 5:

    Length and width of each deep non-linear scar:

    Deep non-linear

    Indicate types of scars and provide measurements(check all that apply):

    Not affected

    Affected

    Specify location of scars on right upper extremity and number them:

    Length and width of each superficial non-linear scar:

    Length of each linear scar:

    Linear

    cm

    Scar # 4:

    cm

    Scar # 1:

    Scar # 3:

    Scar # 5:

    x

    cm

    cm

    x

    Scar # 4:

    x

    cm

    cm

    x

    Scar # 2:

    x

    cm

    If additional scars, list using same format:

    If additional scars, list using same format:

    cm

    x

    Scar # 2:

    x

    cm

    cm

    x

    Scar # 4:

    x

    cm

    cm

    x

    Scar # 5:

    Scar # 3:

    Scar # 1:

    Scar # 1:

    Superficial non-linear

    B. LEFT UPPER EXTREMITY

    If additional scars, list using same format:

    cm

    Scar # 3:

    Scar # 2:

    cm

    cm

    Scar # 5:

    Length and width of each deep non-linear scar:

    Deep non-linear

    Indicate types of scars and provide measurements(check all that apply):

    Not affected

    Affected

    Specify location of scars on left upper extremity and number them:

    Length and width of each superficial non-linear scar:

    Length of each linear scar:

    Linear

    cm

    Scar # 4:

    cm

    Scar # 1:

    Scar # 3:

    Scar # 5:

    x

    cm

    cm

    x

    Scar # 4:

    x

    cm

    cm

    x

    Scar # 2:

    x

    cm

    If additional scars, list using same format:

    If additional scars, list using same format:

    cm

    x

    Scar # 2:

    x

    cm

    cm

    x

    Scar # 4:

    x

    cm

    cm

    x

    Scar # 5:

    Scar # 3:

    Scar # 1:

    Scar # 1:

    Superficial non-linear

    C. RIGHT LOWER EXTREMITY

    If additional scars, list using same format:

    cm

    Scar # 3:

    Scar # 2:

    cm

    cm

    Scar # 5:

    Indicate types of scars and provide measurements(check all that apply):

    Not affected

    Affected

    Specify location of scars on right lower extremity and number them:

    Length of each linear scar:

    Linear

    cm

    Scar # 4:

    cm

    Scar # 1:

    E. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES DUE TO BURNS?

    YES

    NO

    If yes, identify each burn scar and state depth of original burn:

    Burn scar #1:

    Less than deep partial thickness

    Full thickness or sub-dermal

    Deep partial thickness

    Less than deep partial thickness

    Full thickness or sub-dermal

    Deep partial thickness

    Burn scar #2:

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

    SECTION II - SCARS OF THE TRUNK AND EXTREMITIES(Continued)

    DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES(Continued)

    Page 3

    Length and width of each deep non-linear scar:

    Deep non-linear

    Length and width of each superficial non-linear scar:

    Scar # 1:

    Scar # 3:

    Scar # 5:

    x

    cm

    cm

    x

    Scar # 4:

    x

    cm

    cm

    x

    Scar # 2:

    x

    cm

    If additional scars, list using same format:

    If additional scars, list using same format:

    cm

    x

    Scar # 2:

    x

    cm

    cm

    x

    Scar # 4:

    x

    cm

    cm

    x

    Scar # 5:

    Scar # 3:

    Scar # 1:

    Superficial non-linear

    D. LEFT LOWER EXTREMITY

    If additional scars, list using same format:

    cm

    Scar # 3:

    Scar # 2:

    cm

    cm

    Scar # 5:

    Length and width of each deep non-linear scar:

    Deep non-linear

    Indicate types of scars and provide measurements(check all that apply):

    Not affected

    Affected

    Specify location of scars on left lower extremity and number them:

    Length and width of each superficial non-linear scar:

    Length of each linear scar:

    Linear

    cm

    Scar # 4:

    cm

    Scar # 1:

    Scar # 3:

    Scar # 5:

    x

    cm

    cm

    x

    Scar # 4:

    x

    cm

    cm

    x

    Scar # 2:

    x

    cm

    If additional scars, list using same format:

    If additional scars, list using same format:

    cm

    x

    Scar # 2:

    x

    cm

    cm

    x

    Scar # 4:

    x

    cm

    cm

    x

    Scar # 5:

    Scar # 3:

    Scar # 1:

    Scar # 1:

    Superficial non-linear

    E. ANTERIOR TRUNK

    If additional scars, list using same format:

    cm

    Scar # 3:

    Scar # 2:

    cm

    cm

    Scar # 5:

    Length and width of each deep non-linear scar:

    Deep non-linear

    Indicate types of scars and provide measurements(check all that apply):

    Not affected

    Affected

    Specify location of scars on anterior trunk and number them:

    Length and width of each superficial non-linear scar:

    Length of each linear scar:

    Linear

    cm

    Scar # 4:

    cm

    Scar # 1:

    Scar # 3:

    Scar # 5:

    x

    cm

    cm

    x

    Scar # 4:

    x

    cm

    cm

    x

    Scar # 2:

    x

    cm

    If additional scars, list using same format:

    If additional scars, list using same format:

    cm

    x

    Scar # 2:

    x

    cm

    cm

    x

    Scar # 4:

    x

    cm

    cm

    x

    Scar # 5:

    Scar # 3:

    Scar # 1:

    Scar # 1:

    Superficial non-linear

    F. POSTERIOR TRUNK

    If additional scars, list using same format:

    cm

    Scar # 3:

    Scar # 2:

    cm

    cm

    Scar # 5:

    Indicate types of scars and provide measurements(check all that apply):

    Not affected

    Affected

    Specify location of scars on posterior trunk and number them:

    Length of each linear scar:

    Linear

    cm

    Scar # 4:

    cm

    Scar # 1:

    Length and width of each superficial non-linear scar:

    Scar # 1:

    Scar # 3:

    Scar # 5:

    x

    cm

    cm

    x

    Scar # 4:

    x

    cm

    cm

    x

    Scar # 2:

    x

    cm

    If additional scars, list using same format:

    Superficial non-linear

    INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:

    VA FORM 21-0960F-1, MAR 2018

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

    3-1 - MEDICAL HISTORY

    Page 4

    Length and width of each deep non-linear scar:

    Deep non-linear

    If additional scars, list using same format:

    cm

    x

    Scar # 2:

    x

    cm

    cm

    x

    Scar # 4:

    x

    cm

    cm

    x

    Scar # 5:

    Scar # 3:

    Scar # 1:

    SUMMARY OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES

    A. SUPERFICIAL NON-LINEAR SCARS (CHECK ALL THAT APPLY AND PROVIDE APPROXIMATE COMBINED TOTAL AREA IN CENTIMETERS SQUARED FOR EACH AFFECTED ANATOMICAL REGION)

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Anterior trunk:

    Right upper extremity:

    Left upper extremity:

    Right lower extremity:

    None

    Left lower extremity:

    Posterior trunk:

    B. DEEP NON-LINEAR SCARS (CHECK ALL THAT APPLY AND PROVIDE APPROXIMATE COMBINED TOTAL AREA IN CENTIMETERS SQUARED FOR EACH AFFECTED ANATOMICAL REGION)

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Approximate total area:

    cm2

    Anterior trunk:

    Right upper extremity:

    Left upper extremity:

    Right lower extremity:

    None

    Left lower extremity:

    Posterior trunk:

    3. DOES THE VETERAN HAVE ANY SCARS OR DISFIGUREMENT OF HEAD, FACE OR NECK?

    SECTION III - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK

    A. DESCRIBE THE HISTORY(including cause/origin and course) OF THE VETERAN'S SCAR(S) OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK(brief summary):

    B. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK PAINFUL?

    YES

    NO

    If yes, specify the number of painful scars:

    DESCRIBE THE PAIN(if there are multiple painful scars, be sure to adequately identify which scars are painful):

    C. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK UNSTABLE, WITH FREQUENT LOSS OF COVERING OF SKIN OVER THE SCAR?

    YES

    NO

    If yes, specify the number of unstable scars:

    DESCRIBE THE LOSS OF COVERING OF SKIN OVER THE SCAR(if there are multiple unstable scars, be sure to adequately identify which scars are unstable):

    D. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECKBOTH PAINFUL AND UNSTABLE?

    YES

    NO

    If yes, specify number of scars that are both painful and unstable:

    DESCRIBE THE LOCATION OF THESE SCARS:

    E. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK DUE TO BURNS?

    YES

    NO

    If yes, identify each burn scar and state depth of original burn:

    Burn scar #1:

    Less than deep partial thickness

    Deep partial thickness

    Full thickness or sub-dermal

    Less than deep partial thickness

    Full thickness or sub-dermal

    Deep partial thickness

    Burn scar #2:

    YES

    NO

    (If "Yes," complete this section)

    (If "No," skip to Section IV)

    INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS:

    SECTION II - SCARS OF THE TRUNK AND EXTREMITIES(Continued)

    DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES(Continued)

    5 or more

    5 or more

    3

    4

    2

    1

    1

    2

    4

    3

    5 or more

    3

    4

    2

    1

    VA FORM 21-0960F-1, MAR 2018

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

    3-1 - MEDICAL HISTORY(Continued)

    3-2 - PHYSICAL EXAM FOR SCARS OR DISFIGUREMENT OF THE HEAD, FACE AND NECK

    DETAILS OF SCAR OR DISFIGUREMENT FOR THE HEAD, FACE AND NECK

    Page 5

    A. IDENTIFY EACH SCAR OR DISFIGUREMENT AND PROVIDE MEASUREMENTS:

    Disfigurement

    Scar

    Scar/Disfigurement #1

    Indicate type of impairment:

    Length and width (at widest part) of scar/disfigurement #1:

    Location of scar/disfigurement #1:

    x

    cm

    Disfigurement

    Scar

    Scar/Disfigurement #2

    Indicate type of impairment:

    Length and width (at widest part) of scar/disfigurement #2:

    Location of scar/disfigurement #2:

    x

    cm

    Disfigurement

    Scar

    Scar/Disfigurement #4

    Indicate type of impairment:

    Length and width (at widest part) of scar/disfigurement #4:

    Location of scar/disfigurement #4:

    x

    cm

    Disfigurement

    Scar

    Scar/Disfigurement #3

    Indicate type of impairment:

    Length and width (at widest part) of scar/disfigurement #3:

    Location of scar/disfigurement #3:

    x

    cm

    Disfigurement

    Scar

    Scar/Disfigurement #5

    Indicate type of impairment:

    Length and width (at widest part) of scar/disfigurement #5:

    Location of scar/disfigurement #5:

    x

    cm

    If additional scars or disfigurement, list using the same format:

    NO

    YES

    B. IS THERE ELEVATION, DEPRESSION, ADHERENCE TO UNDERLYING TISSUE, OR MISSING UNDERLYING SOFT TISSUE?

    (If yes, check all that apply):

    Surface contour elevated on palpation

    If checked, identify each affected scar/disfigurement:

    Scar/Disfigurement #1

    If checked, identify each affected scar/disfigurement:

    Scar/Disfigurement #5

    Scar/Disfigurement #2

    Other

    Scar/Disfigurement #3

    Scar/Disfigurement #4

    Scar/Disfigurement #1

    If checked, identify each affected scar/disfigurement:

    Scar/Disfigurement #1

    Scar/Disfigurement #4

    Scar/Disfigurement #3

    Other

    Scar/Disfigurement #2

    Scar/Disfigurement #5

    Scar/Disfigurement #5

    Scar/Disfigurement #2

    Other

    Scar/Disfigurement #3

    Scar/Disfigurement #4

    Scar/Disfigurement #1

    Scar/Disfigurement #4

    Scar/Disfigurement #3

    Other

    Scar/Disfigurement #2

    Scar/Disfigurement #5

    Surface contour depressed on palpation

    If checked, identify each affected scar/disfigurement:

    Scar adherent to underlying tissue

    Underlying soft tissue missing

    SECTION III - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK(Continued)

    F. IF THERE ARE ADDITIONAL BURN SCARS OF THE HEAD, FACE OR NECK, LIST USING THE SAME FORMAT:

    VA FORM 21-0960F-1, MAR 2018

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

    SUMMARY OF SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE AND NECK

    DETAILS OF SCAR OR DISFIGUREMENT FOR THE HEAD, FACE AND NECK (Continued)

    SECTION III - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK(Continued)

    Page 6

    NO

    YES

    C. IS THERE ABNORMAL PIGMENTATION OR TEXTURE OF THE HEAD, FACE, OR NECK?

    Hypopigmentation

    Hyperpigmentation

    Induration and inflexibility

    Abnormal texture

    cm2

    cm2

    Describe type of abnormal texture(for example, irregular, atrophic, shiny or scaly):

    NO

    YES

    B. IS THERE GROSS DISTORTION OR ASYMMETRY OF FACIAL FEATURES OR VISIBLE OR PALPABLE TISSUE LOSS?

    Chin

    Ears (auricles) (If checked, specify):

    Nose

    Forehead

    Cheeks

    Complete loss of auricle

    Deformity of auricle, with loss ofone-third or more of the substance

    Side:

    Side:

    Lips

    Left

    Left

    Right

    Right

    Deformity of auricle, with loss ofless than one-third the substance

    Side:

    Left

    Right

    Side:

    Eyes(including eyelids) (If checked, specify):

    Anatomical loss of eye

    Tissue loss/distortion of eyelid

    Left

    Tissue loss/distortion of eye

    Side:

    Side:

    Left

    Left

    Right

    Right

    Right

    A. PROVIDE APPROXIMATE COMBINED TOTAL AREA IN CENTIMETERS SQUARED FOR EACH CHARACTERISTIC OF DISFIGUREMENT:

    1. Approximate total area of head, face and neck with hypo- or hyperpigmented areas:

    2. Approximate total area of head, face and neck with abnormal texture:

    3. Approximate total area of head, face and neck with missing underlying soft tissue:

    4. Approximate total area of head, face and neck that is indurated and inflexible:

    cm2

    cm2

    DISTORTION OF FACIAL FEATURES AND TISSUE LOSS FOR THE HEAD, FACE AND NECK

    If yes, indicate features affected (check all that apply):

    For all checked features, provide brief description of the tissue loss, gross distortion and/or asymmetry of facial features:

    (If yes, check all that apply):

    If checked, identify each affected scar/disfigurement:

    If checked, identify each affected scar/disfigurement:

    Scar/Disfigurement #1

    Scar/Disfigurement #4

    Scar/Disfigurement #3

    Other

    Scar/Disfigurement #2

    Scar/Disfigurement #5

    Scar/Disfigurement #5

    Scar/Disfigurement #2

    Other

    Scar/Disfigurement #3

    Scar/Disfigurement #4

    Scar/Disfigurement #1

    If checked, identify each affected scar/disfigurement:

    Scar/Disfigurement #1

    Scar/Disfigurement #4

    Scar/Disfigurement #3

    Other

    Scar/Disfigurement #2

    Scar/Disfigurement #5

    Scar/Disfigurement #5

    Scar/Disfigurement #2

    Other

    Scar/Disfigurement #3

    Scar/Disfigurement #4

    Scar/Disfigurement #1

    If checked, identify each affected scar/disfigurement:

    VA FORM 21-0960F-1, MAR 2018

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

    Page 7

    SECTION IV - MISCELLANEOUS

    NO

    YES

    4A. DO ANY OF THE SCARS(regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK RESULT IN LIMITATION OF FUNCTION?

    LIMITATION OF FUNCTION/OTHER CONDITIONS

    NOTE: Complete this section for all scars or disfigurements, regardless of location.

    IF YES, INDICATE WHICH SCARS(regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK ARE CAUSING THE LIMITATION AND DESCRIBE THE SPECIFIC LIMITATIONS:

    NO

    YES

    4B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS(such as muscle or nerve damage) ASSOCIATED WITH ANY SCAR(regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK?

    IF YES, DESCRIBE(brief summary):

    4C. PROVIDE COLOR PHOTOGRAPHS FOR ANY SCAR(S) OR DISFIGURING CONDITIONS OF THE HEAD, FACE AND/OR NECK.

    COLOR PHOTOGRAPHS

    Photographs not available

    Photographs provided

    Photographs not indicated

    NO

    YES

    5. DOES THE VETERAN'S SCAR(S)(regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK IMPACT HIS OR HER ABILITY TO WORK?

    SECTION V - FUNCTIONAL IMPACT

    IF YES, DESCRIBE IMPACT OF THE VETERAN'S SCAR(S)(regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK, PROVIDING ONE OR MORE EXAMPLES

    SECTION VI - REMARKS

    CERTIFICATION- To the best of my knowledge, the information contained herein is accurate, complete and current.

    SECTION VII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

    6. REMARKS(if any):

    VA FORM 21-0960F-1, MAR 2018

    PRIVACY ACT NOTICE: 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 the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

    RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 minutes to review the instructions, find the information, and complete the 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 atwww.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.

    IMPORTANT- Physician please fax the completed form to

    (VA Regional Office FAX No.)

    NOTE: VA may obtain additional medical information, including an examination, if necessary to complete VA's review of the veteran's application.

    NOTE: A list of VA Regional Office FAX Numbers can be found atwww.benefits.va.gov/disabilityexamsor obtained by calling 1-800-827-1000.

    7C. DATE SIGNED

    7F. PHYSICIAN'S ADDRESS

    7B. PHYSICIAN'S PRINTED NAME

    7A. PHYSICIAN'S SIGNATURE(Sign in ink)

    7E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

    7D. PHYSICIAN'S PHONE AND FAX NUMBER

    PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

    8.2.1.4029.1.523496.503679

    SCARS / DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE

    VA Form 21-0960F-1

    K. White

    VBA/Comp. Service

    N. Kessinger

    1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK. DIAGNOSIS NUMBER 1.: 1. A. NO.: 0NOTE TO PHYSICIAN: Your patient is applying to the U.S. Department of Veterans Affairs (V. A.) for disability benefits.V. A. will consider the information you provide on this questionnaire as part of their evaluation in processing the veteran's claim. V. A. reserves the right to confirm the authenticity of ALL D B Q's completed by private health care providers. SECTION 1 - DIAGNOSIS. 1. A. DOES THE VETERAN HAVE ONE OR MORE SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK? YES. If "Yes," complete Item 1B.: 01B. DATE OF DIAGNOSIS. Enter 2 digit month, 2 digit day and 4 digit year.: 1B. I C D CODE.: 1B. I C D CODE.: 1B. I C D CODE.: 1B. DIAGNOSIS NUMBER 2.: 1B. DIAGNOSIS NUMBER 3.: 2-1 B. NO.: 02-1 B. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES PAINFUL? YES. If yes, specify the number of painful scars.: 02-1 B. 5 or more.: 02-1 C. NO.: 02-1 C. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES UNSTABLE, WITH FREQUENT LOSS OF COVERING OF SKIN OVER THE SCAR? YES. If yes, specify the number of unstable scars.: 02-1 C. 5 or more.: 02-1 D. NO.: 02-1 D. ARE ANY OF THE SCARS BOTH PAINFUL AND UNSTABLE? YES. If yes, specify number of scars that are both painful and unstable.: 02-1 D. 5 or more.: 03-1 MEDICAL HISTORY. 3-1 A. DESCRIBE THE HISTORY (including cause / origin and course) OF THE VETERAN'S SCAR(S) OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK (brief summary).: 3-1 B. DESCRIBE THE PAIN (if there are multiple painful scars, be sure to adequately identify which scars are painful).: 3-1 C. DESCRIBE THE LOSS OF COVERING OF SKIN OVER THE SCAR (if there are multiple unstable scars, be sure to adequately identify which scars are unstable).: SECTION 3 - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK (Continued). 3-1 - MEDICAL HISTORY (Continued). 3-1 F. IF THERE ARE ADDITIONAL BURN SCARS OF THE HEAD, FACE OR NECK, LIST USING THE SAME FORMAT.: 1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK DUE TO SCARS OR OTHER CAUSES, LIST USING ABOVE FORMAT.: 2. NO. If "No," skip to Section 3.: 0INSTRUCTIONS: Provide all linear measurements in centimeters and area measurements in centimeters squared. For non-linear scars, measure the length and width at their widest points. After measuring the scars, use the summary sections to provide the combined approximate total area for all scars in each region. If scars are too numerous to count (for example, multiple scattered shrapnel wound scars, acne scarring or pseudofolliculitis barbae), indicate T N T C and provide approximate combined total area. NOTE: For V. A. purposes, superficial non-linear scars are those not associated with underlying soft tissue damage, while deep non-linear scars are associated with underlying soft tissue damage. SECTION 2 - SCARS OF THE TRUNK AND EXTREMITIES. 2. DOES THE VETERAN HAVE ANY SCARS ON THE TRUNK OR EXTREMITIES (REGIONS OTHER THAN THE HEAD, FACE OR NECK)? YES. If "Yes," complete this section.: 0NAME OF PATIENT/VETERAN. Middle Initial. 1 Character.: IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (V. A. ) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BEFORE COMPLETING THIS FORM. NAME OF PATIENT/VETERAN. First Name. 12 Characters.: NAME OF PATIENT/VETERAN. Last Name. 18 Characters.: PATIENT/VETERAN'S SOCIAL SECURITY NUMBER. First Three Digits.: PATIENT/VETERAN'S SOCIAL SECURITY NUMBER. Middle 2 digits.: PATIENT/VETERAN'S SOCIAL SECURITY NUMBER. Last Four Digits.: 2-2 C. If additional scars, list using same format.: 3-2 A. Length and width (at widest part) of scar/disfigurement number 5. Length in centimeters.: 2-2 A. RIGHT UPPER EXTREMITY. Not Affected.: 02-2 A. Deep non-linear.: 02-2 A. Superficial non-linear.: 02-2 A. Indicate types of scars and provide measurements (check all that apply). Linear.: 02-2 - PHYSICAL EXAM FOR SCARS ON THE TRUNK AND EXTREMITIES. DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES. INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS. 2-2 A. RIGHT UPPER EXTREMITY. Affected.: 03-2 A. Width in centimeters.: 2-2 B. LEFT UPPER EXTREMITY. Not Affected.: 02-2 B. Deep non-linear.: 02-2 B. Superficial non-linear.: 02-2 B. Indicate types of scars and provide measurements (check all that apply). Linear.: 02-2 B. LEFT UPPER EXTREMITY. Affected.: 02-2 B. Specify location of scars on left upper extremity and number them.: 2-2 C. RIGHT LOWER EXTREMITY. Not Affected.: 02-2 C. Indicate types of scars and provide measurements (check all that apply). Linear.: 02-2 C. RIGHT LOWER EXTREMITY. Affected.: 03-2 C. Specify other.: 2-2 A. Specify location of scars on right upper extremity and number them.: 2-1 E. NO.: 02-1 E. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES DUE TO BURNS? YES. If yes, identify each burn scar and state depth of original burn.: 0E. Burn scar number 2. Less than deep partial thickness.: 0E. Burn scar number 1. Less than deep partial thickness.: 02-1 E. If yes, identify each burn scar and state depth of original burn. Burn scar number 2.: 2-2 C. Deep non-linear.: 0SECTION 2 - SCARS OF THE TRUNK AND EXTREMITIES (Continued). DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES (Continued). INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS. 2-2 C. Superficial non-linear.: 02-2 D. LEFT LOWER EXTREMITY. Not Affected.: 02-2 D. Deep non-linear.: 02-2 D. Superficial non-linear.: 02-2 D. Indicate types of scars and provide measurements (check all that apply). Linear.: 02-2 D. LEFT LOWER EXTREMITY. Affected.: 02-2 E. ANTERIOR TRUNK. Not Affected.: 02-2 E. Deep non-linear.: 02-2 E. Superficial non-linear.: 02-2 E. Indicate types of scars and provide measurements (check all that apply). Linear.: 02-2 E. ANTERIOR TRUNK. Affected.: 02-2 F. POSTERIOR TRUNK. Not Affected.: 02-2 F. Indicate types of scars and provide measurements (check all that apply). Linear.: 02-2 F. POSTERIOR TRUNK. Affected.: 02-2 F. Superficial non-linear.: 0SECTION 2 - SCARS OF THE TRUNK AND EXTREMITIES (Continued). DETAILS OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES (Continued). INDICATE THE ANATOMICAL REGIONS AFFECTED AND COMPLETE APPROPRIATE SECTIONS. 2-2 F. Deep non-linear.: 0A. 4. Approximate total area of head, face and neck that is indurated and inflexible in centimeters squared.: A. SUPERFICIAL NON-LINEAR SCARS. Posterior trunk.: 0A. SUPERFICIAL NON-LINEAR SCARS. Anterior trunk.: 0A. SUPERFICIAL NON-LINEAR SCARS. Left lower extremity.: 0A. SUPERFICIAL NON-LINEAR SCARS. Right lower extremity.: 0A. SUPERFICIAL NON-LINEAR SCARS. Left upper extremity.: 0A. SUPERFICIAL NON-LINEAR SCARS. Right upper extremity.: 0SUMMARY OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES. A. SUPERFICIAL NON-LINEAR SCARS (CHECK ALL THAT APPLY AND PROVIDE APPROXIMATE COMBINED TOTAL AREA IN CENTIMETERS SQUARED FOR EACH AFFECTED ANATOMICAL REGION). None.: 0B. DEEP NON-LINEAR SCARS. Posterior trunk.: 0B. DEEP NON-LINEAR SCARS. Anterior trunk.: 0B. DEEP NON-LINEAR SCARS. Left lower extremity.: 0B. DEEP NON-LINEAR SCARS. Right lower extremity.: 0B. DEEP NON-LINEAR SCARS. Left upper extremity.: 0B. DEEP NON-LINEAR SCARS. Right upper extremity.: 0B. DEEP NON-LINEAR SCARS (CHECK ALL THAT APPLY AND PROVIDE APPROXIMATE COMBINED TOTAL AREA IN CENTIMETERS SQUARED FOR EACH AFFECTED ANATOMICAL REGION). None.: 03-1 B. NO.: 03-1 B. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK PAINFUL? YES. If yes, specify the number of painful scars.: 03-1 C. NO.: 03-1 C. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK UNSTABLE, WITH FREQUENT LOSS OF COVERING OF SKIN OVER THE SCAR? YES. If yes, specify the number of unstable scars.: 03-1 D. NO.: 03-1 D. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK BOTH PAINFUL AND UNSTABLE? YES. If yes, specify number of scars that are both painful and unstable.: 03-1 E. NO.: 03-1 E. ARE ANY OF THE SCARS OF THE HEAD, FACE OR NECK DUE TO BURNS? YES. If yes, identify each burn scar and state depth of original burn.: 03-1 E. If yes, identify each burn scar and state depth of original burn. Burn scar number 1.: 3-1 E. Burn scar number 2. Full thickness or sub-dermal.: 03-1 E. Less than deep partial thickness.: 0E. If yes, identify each burn scar and state depth of original burn. Burn scar number 2.: SECTION 3 - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK. 3. DOES THE VETERAN HAVE ANY SCARS OR DISFIGUREMENT OF HEAD, FACE OR NECK? YES. If "Yes," complete this section.: 03. NO. If "No," skip to Section 4.: 03-1 C. If yes, specify the number of unstable scars. 1.: 03-1 D. 5 or more.: 03-1 B. 5 or more.: 03-2 - PHYSICAL EXAM FOR SCARS OR DISFIGUREMENT OF THE HEAD, FACE AND NECK. DETAILS OF SCAR OR DISFIGUREMENT FOR THE HEAD, FACE AND NECK. 3-2 A. IDENTIFY EACH SCAR OR DISFIGUREMENT AND PROVIDE MEASUREMENTS. Scar/Disfigurement Number 1. Indicate type of impairment. Scar. : 03-2 A. Location of scar/disfigurement number 5.: 3-2 A. Scar/Disfigurement Number 2. Indicate type of impairment. Scar.: 03-2 A. Scar/Disfigurement Number 4. Indicate type of impairment. Scar.: 03-2 A. Scar/Disfigurement Number 3. Indicate type of impairment. Scar.: 03-2 A. Scar/Disfigurement Number 5. Indicate type of impairment. Scar.: 03-2 B. If checked, identify each affected scar/disfigurement. Scar/Disfigurement Number 1.: 03-2 B. Other.: 03-2 B. If checked, identify each affected scar/disfigurement. Scar/Disfigurement Number 1.: 03-2 B. If yes, check all that apply. Surface contour elevated on palpation. If checked, identify each affected scar/disfigurement.: 03-2 B. Other.: 03-2 B. IS THERE ELEVATION, DEPRESSION, ADHERENCE TO UNDERLYING TISSUE, OR MISSING UNDERLYING SOFT TISSUE? YES. If yes, check all that apply.: 0B. NO.: 03-2 B. Surface contour depressed on palpation. If checked, identify each affected scar/disfigurement.: 03-2 B. Scar adherent to underlying tissue. If checked, identify each affected scar/disfigurement.: 03-2 B. Underlying soft tissue missing. If checked, identify each affected scar/disfigurement.: 03-2 A. If additional scars or disfigurement, list using the same format.: 3-2 C. If yes, check all that apply. Hypopigmentation. If checked, identify each affected scar/disfigurement.: 0SECTION 3 - SCARS OR OTHER DISFIGUREMENT OF THE HEAD, FACE OR NECK (Continued). DETAILS OF SCAR OR DISFIGUREMENT FOR THE HEAD, FACE AND NECK (Continued). 3-2 C. IS THERE ABNORMAL PIGMENTATION OR TEXTURE OF THE HEAD, FACE, OR NECK? YES. If yes, check all that apply.: 03-2 C. NO.: 03-2 C. Hyperpigmentation. If checked, identify each affected scar/disfigurement.: 03-2 C. Induration and inflexibility. If checked, identify each affected scar/disfigurement.: 03-2 C. Abnormal texture. If checked, identify each affected scar/disfigurement.: 03-2 C. Describe type of abnormal texture (for example, irregular, atrophic, shiny or scaly).: DISTORTION OF FACIAL FEATURES AND TISSUE LOSS FOR THE HEAD, FACE AND NECK. B. IS THERE GROSS DISTORTION OR ASYMMETRY OF FACIAL FEATURES OR VISIBLE OR PALPABLE TISSUE LOSS? YES. If yes, indicate features affected (check all that apply).: 0B. If, "Yes," indicate features affected (check all that apply). Nose.: 0B. Chin.: 0B. Forehead.: 0B. Cheeks.: 0B. Lips.: 0B. If, "Yes," indicate features affected (check all that apply). Eyes (including eyelids) (If checked, specify).: 0B. If, "Yes," indicate features affected (check all that apply). Ears (auricles) (If checked, specify).: 0B. Eyes (including eyelids) (If checked, specify). Tissue loss/distortion of eyelid. : 0B. Eyes (including eyelids) (If checked, specify). Tissue loss/distortion of eye.: 0B. Eyes (including eyelids) (If checked, specify). Anatomical loss of eye.: 0B. Ears (auricles) (If checked, specify). Complete loss of auricle.: 0B. Ears (auricles) (If checked, specify). Deformity of auricle, with loss of less than one-third the substance.: 0B. Ears (auricles) (If checked, specify). Deformity of auricle, with loss of one-third or more of the substance.: 0B. Tissue loss/distortion of eyelid. Side. Right.: 0B. Side. Left.: 0B. Tissue loss/distortion of eye. Side. Right.: 0B. Side. Left.: 0B. Anatomical loss of eye. Side. Right.: 0B. Side. Left.: 0B. Complete loss of auricle. Side. Right.: 0B. Side. Left.: 0B. Deformity of auricle, with loss of less than one-third the substance. Side. Right.: 0B. Side. Left.: 0B. Deformity of auricle, with loss of one-third or more of the substance. Side. Right.: 0B. Side. Left.: 0B. NO.: 0B. For all checked features, provide brief description of the tissue loss, gross distortion and/or asymmetry of facial features.: 3-2 C. Other.: 03-2 C. If checked, identify each affected scar/disfigurement. Scar/Disfigurement Number 1.: 03-2 C. Other.: 03-2 C. If checked, identify each affected scar/disfigurement. Scar/Disfigurement Number 1.: 04. A. NO.: 0SECTION 4 - MISCELLANEOUS. NOTE: Complete this section for all scars or disfigurements, regardless of location. LIMITATION OF FUNCTION/OTHER CONDITIONS. 4. A. DO ANY OF THE SCARS (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK RESULT IN LIMITATION OF FUNCTION? YES. IF YES, INDICATE WHICH SCARS (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK ARE CAUSING THE LIMITATION AND DESCRIBE THE SPECIFIC LIMITATIONS.: 04B. NO.: 04B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (such as muscle or nerve damage) ASSOCIATED WITH ANY SCAR (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK? YES. IF YES, DESCRIBE (brief summary).: 0COLOR PHOTOGRAPHS. 4C. PROVIDE COLOR PHOTOGRAPHS FOR ANY SCAR(S) OR DISFIGURING CONDITIONS OF THE HEAD, FACE AND/OR NECK. Photographs not indicated.: 05. NO.: 0SECTION 5 - FUNCTIONAL IMPACT. 5. DOES THE VETERAN'S SCAR(S) (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK IMPACT HIS OR HER ABILITY TO WORK? YES. IF YES, DESCRIBE IMPACT OF THE VETERAN'S SCAR(S) (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK, PROVIDING ONE OR MORE EXAMPLES.: 0SECTION 6 - REMARKS. 6. REMARKS (if any).: 5. IF YES, DESCRIBE IMPACT OF THE VETERAN'S SCAR(S) (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK, PROVIDING ONE OR MORE EXAMPLES.: 4. A. IF YES, INDICATE WHICH SCARS (regardless of location) OR DISFIGUREMENT OF THE HEAD, FACE OR NECK ARE CAUSING THE LIMITATION AND DESCRIBE THE SPECIFIC LIMITATIONS.: 4B. IF YES, DESCRIBE (brief summary).: NOTE: V. A. may obtain additional medical information, including an examination, if necessary to complete V. A.'s review of the veteran's application. IMPORTANT- Physician please fax the completed form to V. A. Regional Office FAX Number.: 7. F. PHYSICIAN'S ADDRESS.: 7. C. DATE SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.: 7. B. PHYSICIAN'S PRINTED NAME.: 7. E. NATIONAL PROVIDER IDENTIFIER (N P I) NUMBER.: 7. D. PHYSICIAN'S PHONE AND FAX NUMBER.: SECTION 7 - PHYSICIAN'S CERTIFICATION AND SIGNATURE. CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.7. A. Physician's Signature (Sign in ink). This signature field can not be signed with a digital signature and the signee's name can not be typewritten into this space. This is a protected field. Please print the document and sign in ink.:

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