Service Connection Statement

Service Connection Statement

Please complete a statement form for EACH claim you intend to pursue. If you have any questions, please contact your case manager for more information.
Timer
Your Name*

First NameLast Name
Phone Number*
Please include your area code
Email Address
example@example.com
Who asked you to complete this form?*
What device are you using to complete this form?*

HOW IS THIS CONDITION RELATED TO YOUR MILITARY SERVICE?
YOU MUST ANSWER YES TO AT LEAST ONE OF THE FOUR QUESTIONS BELOW.

If you answer NO to ALL questions below, you will not be able to complete a statement for this condition.
Please answer the following questions about your claim for

{whichMedical}

What is service-connection?
Click for more information on what service-connection means and how the VA determines whether a condition is related to service.
Did an injury in service cause your {whichMedical} claim?*
This means that you suffered an injury while you were in service that caused this condition.

Examples:
- hit with a blunt object
- fell down and twisted joint
- broke a bone
- piece of equipment fell on top of me
- fell off of repair tank
Do you believe your {whichMedical} claim was caused by the demands of your military service?*
This means that this condition was caused by the constant wear and tear of your job while you were in service.

Examples:
- picking up 50LB boxes everyday caused back or knee problems
- marching long distances with heavy equipment caused foot or ankle conditions
This is a common cause of many orthopedic conditions.
Do you believe your {whichMedical} claim was caused by exposure to one or more toxins or chemicals while you were in service?*
This means that this condition was caused by an exposure to a toxin or chemical during service:

Examples:
- migraines due to exposure to jet fuel
- heart condition due to exposure to asbestos
- diabetes mellitus due to exposure to firefighting foam
Do you believe your {whichMedical} claim was caused or aggravated by another condition?*
This means that this condition was caused by another medical condition.

Examples:
- knee condition due to a back injury
- peripheral neuropathies due to diabetes mellitus II
- migraines due to tinnitus
- depression due to an orthopedic condition
ERROR:

At least ONE of the questions above must be YES in order to proceed.

DIRECT INJURY IN SERVICE
Please answer the following questions about your claim for {whichMedical}.
Describe WHAT happened in service that caused this injury.*
Please use specific details to describe the event.
WHERE were you stationed when this injury happened?*
Please give the name of the base you were stationed at with the state/country
WHEN did this injury happen? (Month and Year)*
If you do not rememver the exact date, please provide a 3-month period and yearExample: March-May 1992
Did you receive treatment for this injury right after it happened?*
What kind of treatment did you receive?*
Did anyone else SEE this injury when it occurred?*
Who saw this injury happen in service?*
Did you tell anyone about this injury when it happened?*
Who did you tell and when?*
Did you tell a spouse or family member?

SECONDARY
Please answer the following questions about your claim for {whichMedical}.
What other condition caused or aggravated this condition?*
WHY do you think this other condition caused or contributed to your {whichMedical}?*

EMPLOYMENT
Describe how your symptoms related to your {whichMedical} have affected your ability to work. *
Please use multiple specific details.
Consider the following examples of how your symptoms may have impacted your ability to work:
- Have you missed days of work due to your symptoms?
  - how many work days?
  - did you need a doctor's note?
  - has this affected your pay?
- Have your symptoms led to lower productivity at work? Describe all tasks you struggle with or can no longer complete.
  - Do you require help to complete these tasks?
  - Does this affect your pay?
  - Does this affect your mental health?
- Do your symptoms affect your physical appearance such as bathing and grooming?
- Have your symptoms strained your family relationships and friendships/relationships with coworkers?
- Have you had trouble traveling because of your symptoms?

REVIEW & SUBMIT
Please answer the following questions about your claim for {whichMedical}.
Is there anything else you would like to add to your statement?
Upload any additional evidence here.

Attach any medical journal articles, treatment notes, etc. to support the fact that your newly claimed condition is related to your service-connected condition or medication prescribed.
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Service Connection Statement

THIS STATEMENT IS ABOUT ...

Unless otherwise instructed, please complete a separate statement for EACH medical condition or disability in your case.

HOW IS THIS CONDITION RELATED TO YOUR MILITARY SERVICE?

YOU MUST ANSWER YES TO AT LEAST ONE OF THE FOUR QUESTIONS BELOW.

Please answer the following questions about your claim for

{whichMedical}

ERROR:

At least ONE of the questions above must be YES in order to proceed.

DIRECT INJURY IN SERVICE

Please answer the following questions about your claim for {whichMedical}.

CHRONIC SYMPTOMS OVER TIME

Please answer the following questions about your claim for {whichMedical}.

If you were in the National Guard or Reserves, your active duty time is when you were in: (1) basic training, (2) advanced individual training (AIT) or specialized training, and/or (3) all deployments or overseas service.

TOXIC EXPOSURE

Please answer the following questions about your claim for {whichMedical}.

CHEMICALS AND HERBICIDES

FOAMS AND FUELS

HEAVY METALS AND RADIOACTIVE MATERIALS

INDUSTRIAL SOLVENTS AND OCCUPATIONAL HAZARDS

OTHER TYPE OF EXPOSURE

SECONDARY

Please answer the following questions about your claim for {whichMedical}.

CURRENT SYMPTOMS

Please answer the following questions to build a timeline of your symptoms related to your claim for {whichMedical}.

EMPLOYMENT

REVIEW & SUBMIT

Please answer the following questions about your claim for {whichMedical}.